NHS Lanarkshire Stop Smoking Services THIS FORM CAN BE USED TO REFER PATIENTS FROM A PHARMACY TO THE LANARKSHIRE STOP SMOKING SERVICE OR VICE VERSA. Patient Details Name: CHI No: Contact Tel no (incl code) Address: Mobile Date of Birth: Post Code: (dd/mm/yy) GP Name: GP Surgery Relevant Medical History (e.g. please state if pregnant, had recent MI (heart attack)/stroke? Additional comments e.g. why patient now has preference to change location for support. In most cases, with the patient’s permission, it would also be useful to include a copy of the patients Lanarkshire Stop Smoking Client record with the referral. Referral Details – please complete as fully as possible to enable us to process each referral efficiently. Pharmacy stamp/pharmacy details Referred by Pharmacy Referral date Contact Number Referred to - please complete as fully as possible to enable us to process each referral efficiently. Smoking Cessation Base/or Pharmacy Permission to contact you Yes No Permission to share data Yes No Signature: Other Which appointment time suits best? Do you have a disability that would interfere Yes No Morning Afternoon Evening with your ability to attend the service? Office Use Only Date referral received Database No Appointment date Time Venue For details of where to return referral forms please turn over NHS Lanarkshire Stop Smoking Services Area Address Contact Number Catchment Area Stop Smoking Service Airdrie, Chapelhall, Wester Moffat Hospital Caldercruix, Airdrie 01236 771065 Calderbank, Plains & Towers Road, Airdrie Newarthill ML6 8LW Stop Smoking Service Bellshill Bellshill & Viewpark The Gatehouse Motherwell Motherwell 01698 863258 Cleland Hospital, Cleland Wishaw, Newmains, Wishaw ML1 5NR Shotts & Harthill Stop Smoking Service Coathill Hospital Coatbridge, Bargeddie Coatbridge 01236 707714 Hospital Street, Coatbridge & Glenboig ML5 4DN Stop Smoking Service Biggar, Carluke, Roadmeetings Hospital Carstairs & Carnwath, Clydesdale 01555 773637 Goremire Rd, Carluke Douglas, Lanark, ML8 4PS Larkhall, Lesmahagow, Stop Smoking Service Central Health Centre, Cumbernauld 01236 727005 Cumbernauld & Kilsyth North Carbrain, Cumbernauld G67 1BJ Stop Smoking Service Red Deer Centre East Kilbride & East Kilbride 01355 593474 Alberta Ave, East Kilbride Strathaven G75 8NH Stop Smoking Service Udston Hospital Hamilton Farm Road, Burnbank, 01698 723240 Hamilton & Blantyre Hamilton, ML3 9LA Stop Smoking Service Hospital inpatients/ Monklands District Monklands Hospital 01236 712779 outpatients/ General Hospital Monkscourt Ave, Airdrie staff ML6 0JS Stop Smoking Service Hospital inpatients/ Wishaw General Wishaw General Hospital 01698 366466 outpatients/ Hospital 50 Netherton Street, Wishaw staff ML2 0DP Stop Smoking Service Hairmyres Hospital Hospital inpatients/ Hairmyres Hospital Eaglesham Road, East Kilbride 01355 585000 outpatients/ Glasgow staff G75 8RG .