Services > K'aute Pasifika Clinic > Pacific Smokefree Services

Pacific Smokefree Services

We offer a free Smokefree service for Pacific people and their aiga. Our qualified Pacific quit coach will provide one-on-one support and wraparound services to help you achieve your goals.

Who can access

We are targeting Pacific people, but also open to anyone who wants to quit smoking

We can help you

Aiga/whānau are provided with free NRT i.e. patches, gum and lozenges or a tailored plan will be developed to meet the needs of the individual or wider whānau
Our nationally qualified Pacific stop smoking coach will provide motivation support for up to 4 weeks

Access this service

Complete the referral form Contact us

Smokefree services referral form

Congratulations for taking the first step in becoming Smokefree! We offer free one-on-one support. Please complete this form and our Smokefree coach will contact you.

Personal Details

First Name *

Last Name *

Date of birth *

Email *

Home Ph

Other Ph/Mobile

Street Address *

Suburb *

Town/City *

Post code: *

Don't know your postcode? Use the NZPost Postcode Finder

NHI Number

Contact Details

Next of Kin

Next of Kin Phone

Next of Kin Address

Doctor/Midwife (name)

Doctor/Midwife Address/Contact

Doctor/Midwife Phone

Questions about your smoking

How many cigarettes do you usually smoke each day?

How many of these are hand-rolled cigarettes?

If yes, how many cigarettes per day did you use to smoke?

How much money are you spending on tobacco per week?

If other, please give us details

About how many cigarettes did you smoke per day in the last week?

Smokefree Environments

Please show for each of the symptoms below how you have been feeling over the past week

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