Oxfordshire Stop Smoking Service Referral Form

Healthy Lifestyle support is for:

Myself

Someone else

Please select your booking type:

I would like to book my assessment

Please contact me instead

Your details:

Date of birth:

Your Postcode:

If you cannot find a time that suits you please call our office on 0800 122 3790 where we may be able to assist you further.

Once you click 'submit', your completed form and all the information it contains are safely encrypted and transferred to a secure database.

Please note that we aim to contact you within two full working days of receiving your information.

Thank you for your co-operation

First name(s)

Last name

Gender

Date of birth

Contact number

Mobile number

Postal address

Email address

Postcode

Please tick the box if any of these apply to you:

Pregnant

Employed

Unable to work due to sickness/disability

Long Term Condition

How did you find out about the service?

How did you find out about the Stop Smoking Service?

Client consent

I consent to being referred to the Oxfordshire Stop Smoking Service, the nature and purpose of which has been explained by my referrer.

I consent to the release of relevant personal information about myself to the Oxfordshire Stop Smoking Service. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controller is my referrer.

I understand that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information.

Consent to process personal data

Please tick this box if you consent to this service

Introduction

Your data is required to:

Assist us in delivering the most suitable service to meet your specific needs
Accurately monitor your progress throughout the programme
Ensure that our services remain current and effective

Acceptance

I consent for my personal details to be held by Oxfordshire Stop Smoking Service. I understand the service will hold my personal data for up to five years, which will allow me to re-enter the service during that time. I understand I have the right to ask for my data to be deleted from the service records at any time. I understand that anything I disclose to a health coach will be treated in the strictest confidence and will only be shared with other services with my permission or for legal reasons that ICE Creates Ltd are obliged to uphold.

I consent for the service to use my details for statistical and analysis purposes only, and understand that my confidentiality will be maintained always, and all information will be stored in accordance with ICE Creates Ltd data protection policy and procedures, and that my personal identifiable details will not be used in any reports without my permission.

Obtaining Consent

We have checked that consent is one of the appropriate lawful basis for processing and have made the request for consent prominent and separate from our terms and conditions when we ask people to positively opt in.

We don't use pre-ticked boxes, or any other type of consent by default in fact we use clear, plain language that is easy to understand and inform you specifically why we want the data and what we're going to do with it.

You have the right to withdraw your consent without detriment to you and you have the right to refuse to consent without detriment. You also have the right to request a copy of the information we hold about you in an easy to read and transferable format

If you refuse to provide consent it will be difficult for us to provide a lifestyle services to you for clinical and safety reasons, in addition, we must obtain and maintain accurate details about you.

Managing Consent

We record consent by storing when and how we were provided with your consent and exactly what you were told at the time.

We will not share your data with other service providers without your agreement and your data will not be transferred outside of the UK.

We regularly review consent to check that the relationship, the processing and the purposes have not changed.

We have processes in place to refresh consent at appropriate intervals. It is an easy process for individuals to withdraw their consent at any time, and we act on withdrawals of consent as soon as we can. Additionally, we don't penalise individuals who wish to withdraw consent.

For the individual being referred

I can obtain further information about how my personal data is processed on the service privacy notice, which includes the right to withdraw consent to this referral and sharing my progress with the referrer. This can be reached at http://stopforlife.co.uk/privacy-and-cookies-policies/ and a copy is also available from the Oxfordshire Stop Smoking Service upon request.

Referrer’s details:

Your name

Your organisation

Your job title

Your email

Your tel no

Client's/Patient's details:

Is your patient pregnant?

Yes

No

Midwife details (if not listed above)

First name(s)

Last name

Gender

Date of birth

Contact number

Mobile number

Postal address

Email address

Postcode

In order to ensure we can offer the client/patient the appropriate level of service, it is important we have the following information.

Please tick the box if any of these apply:

Employed

Unable to work due to sickness/disability

Long Term Condition

Known issues/additional comments

Client consent (to be confirmed by client)

I consent to being referred to the Oxfordshire Stop Smoking Service, the nature and purpose of which has been explained by my referrer.

I consent to the release of relevant personal information about myself to the Oxfordshire Stop Smoking Service. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controller is my referrer.

I understand that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information.

Consent to process personal data

Please tick this box if you the individual has consented to this service’

Introduction

Your data is required to:

Assist us in delivering the most suitable service to meet your specific needs
Accurately monitor your progress throughout the programme
Ensure that our services remain current and effective

Acceptance

I consent for my personal details to be held by Oxfordshire Stop Smoking Service. I understand the service will hold my personal data for up to five years, which will allow me to re-enter the service during that time. I understand I have the right to ask for my data to be deleted from the service records at any time. I understand that anything I disclose to a health coach will be treated in the strictest confidence and will only be shared with other services with my permission or for legal reasons that ICE Creates Ltd are obliged to uphold.

I consent for the service to use my details for statistical and analysis purposes only, and understand that my confidentiality will be maintained always, and all information will be stored in accordance with ICE Creates Ltd data protection policy and procedures, and that my personal identifiable details will not be used in any reports without my permission.

Obtaining Consent

We have checked that consent is one of the appropriate lawful basis for processing and have made the request for consent prominent and separate from our terms and conditions when we ask people to positively opt in.

We don't use pre-ticked boxes, or any other type of consent by default in fact we use clear, plain language that is easy to understand and inform you specifically why we want the data and what we're going to do with it.

You have the right to withdraw your consent without detriment to you and you have the right to refuse to consent without detriment. You also have the right to request a copy of the information we hold about you in an easy to read and transferable format

If you refuse to provide consent it will be difficult for us to provide a lifestyle services to you for clinical and safety reasons, in addition, we must obtain and maintain accurate details about you.

Managing Consent

We record consent by storing when and how we were provided with your consent and exactly what you were told at the time.

We will not share your data with other service providers without your agreement and your data will not be transferred outside of the UK.

We regularly review consent to check that the relationship, the processing and the purposes have not changed.

We have processes in place to refresh consent at appropriate intervals. It is an easy process for individuals to withdraw their consent at any time, and we act on withdrawals of consent as soon as we can. Additionally, we don't penalise individuals who wish to withdraw consent.

For the individual being referred

I can obtain further information about how my personal data is processed on the service privacy notice, which includes the right to withdraw consent to this referral and sharing my progress with the referrer. This can be reached at http://stopforlife.co.uk/privacy-and-cookies-policies/ and a copy is also available from the Oxfordshire Stop Smoking Service upon request.

I recommend for the above person to be referred to the Oxfordshire Stop Smoking Service to receive onward signposting and support.

I confirm that I have assessed this person, and to my knowledge there is no medical reason why they should not be referred.

I confirm that I have discussed this referral, and the reasoning for it, with the person named above

I would like to be kept up to date on the progress of this referral should the subject give their consent