Stop Smoking Register Te Hā Waitaha Referral Form Date* DD slash MM slash YYYY Name* First Last Phone*Address Street Address Address Line 2 City ZIP / Postal Code Email COVID-19 Vaccination StatusYou do not need to be vaccinated to access our services, however, your vaccination status may affect the way our services are delivered (e.g. numbers for group programmes etc).Please select one of the following options: I am fully vaccinated I am partially vaccinated I am not vaccinated Not sure / Prefer not to answer Comments (optional)CAPTCHA
