Physicians's Referral Form

>En Español

"My Quit Coach was very helpful and helped me considerably with trying to quit."

Required Fields
Provider Information
Clinic Name:
Health Care Provider:
Contact Name:
I am a HIPAA-Covered Entity (Please check one):
	Yes:
	No:
I don't know:
Fax:		(e.g. 512-555-1212)
Phone:		(e.g. 512-555-1212)
Zip Code:
Provider Comments:
Patient Information
Gender:
	Male
	Female
Pregnant:
	Yes
	No
Patient Name:
Date of Birth:		(e.g. dd/mm/yyyy)
Patient Address:
City:
Zip:
Primary Number:		(e.g. 512-555-1212)
Primary Number Type:
	Home
	Work
	Cell
	Other
Secondary Number:		(e.g. 512-555-1212)
Secondary Number Type:
	Home
	Work
	Cell
	Other
Language Preference (check one):
	English
	Spanish
	Other
Tobacco Type (check ALL that apply):
Cigarettes
Smokeless Tobacco
Cigar
Pipe
The patient is ready to quit tobacco in the next 30 days and requests the Quitline contact him or her with quit plan help.
The patient DOES NOT give permission to the Quitline to leave a message when contacting him or her.
The patient agrees and accepts the terms of this form submission.
The Quitline will call the patient. Please check the BEST three-hour time frame for them to reach the patient. NOTE: The Quitline is open seven days a week; call attempts over a weekend may be made at times other than during this three-hour time frame.
6 am - 9 am
9 am - 12 pm
12 pm - 3 pm
3 pm - 6 pm
6 pm - 9 pm
Within this three-hour time frame, please contact the patient at (check one):
Primary Number
Secondary Number

>Yes You Can