Smoke Cessation Clinic Referral Form

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Smoke cessation clinic is run by one of RSDC doctors (Respiratory Physician) and a dedicated respiratory nurse with previous experience in delivering smoke cessation care.

Smoke Cessation Clinic Referral Form

Fill all required fields (★) to submit the form.

Patient details:

Full Name:(Required)

Preferred name:

Date of birth:(Required)

Mobile Number:(Required)

Home Phone:

Address:

Email address(Required)

Please choose your preferred location:

Clinic:(Required)

RSDC Ferntree Gully
719 Burwood Hwy, Ferntree Gully VIC 3156

RSDC Epworth Camberwell
Suite 2 Epworth Camberwell, 888 Toorak Rd, Camberwell VIC 3124

RSDC Knox
Suite 2a Knox Private Hospital, 262 Mountain Hwy, Wantirna VIC 3152

RSDC Balwyn North
345 Doncaster Rd, Balwyn North Vic 3104

RSDC Richmond
2a, Bridge Rd, Richmond Vic 3121

Please review for consideration of smoke cessation.

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Signature

Doctor’s Name

Lung Care

We care about your Lungs!

Lung Cancer Screening Program (LCSP)

Smoke Cessation Clinic Referral Form