DHB Register

Hospital Details

Referrer name

Website referrer organisation

Referral date

NHI

Referral Notes

A bit about you

First Name

Middle Name

Last Name

Ethnicity

Gender

Date of birth

Order Nrt

Do you want to order NRT for your patient?

Contact details

Street

Suburb

City

Postcode

Mobile

Home

Work

Yes, I would like to make myself available for research

Smoking Habits

What do you mainly use

How soon after you wake up do you have your first smoke/vape?

Are you living with someone who smokes?

What is your most common trigger to start smoking?

How likely is it that you’d reach for a smoke/vape when you’re feeling down, stressed anxious, or grumpy

What is your main reason to quit at this time?

How supported do you feel by friends and whānau with your quit attempt?

How confident are you that you can quit smoking?

Programme Preferences

Are you currently pregnant?

Select your quit start date

How would you like to be contacted?

Text support

Phone support

What language would you prefer to receive SMS in?

Preferred Callback Date