Healthcare professionals referral form

Client details

Is the client an inpatient?

Toggle No Yes

Hospital

Ward

Expected discharge date

Title

Client first name

Client surname

Address Line 1

Address Line 2

Postcode

Client email address

Contact number

Deaf or hard of hearing?

Toggle No Yes

Preferred language?

English Cymraeg Other

Preferred callback time?

Morning Afternoon Evening

Referrer details

Please fill in the form with your own details, as a referring healthcare professional.

Title

First name

Surname

Health board

Referral type

Name of referring organisation eg Llynfi Surgery, Glan Clwyd Hospital

How we use your and your clients' information.

Public Health Wales is conducting research into the experiences, needs, and perspectives of adults aged 55–74 who smoke or have quit smoking in the past five years. We are interested in hearing from primary care professionals working in general practice, dentistry, optometry, and pharmacy in Wales who regularly see patients in this age group.

What Participation Involves

 A 1:1 online interview with a researcher.
The interview will be no longer than 45 minutes.
The interview will be flexible around your schedule.

Participation is entirely voluntary and not financially compensated, but your insights would be extremely valuable.

For more information and to register your interest, please follow the link: https://forms.cloud.microsoft/e/3rBG0bpmHk

A full Participant Information Sheet and consent form will be provided.