Québec sans tabac : portail de la lutte contre le tabagisme

Patient reference form from health facilities

These forms are for health care providers who want to refer their smoking patient to the I QUIT NOW services. The patient should receive a phone call in 1 or 2 business days after you have submitted the form. The specialists of the I QUIT NOW quitline will receive the completed forms and will offer patients the help of the I QUIT NOW services consisting of:

Online help offered by the I QUIT NOW website;
Help by phone offered by the I QUIT NOW quitline;
Help in person offered by the Quit Smoking Centres of their region;
Help by text message offered by the SMAT.

Patient availability

Patient's gender

Patient first name

Patient last name

Patient phone number

Language

Health Care Provider

Health Care Provider first name

Health Care Provider last name

Falicity name

Department/Unity

Health Care Provider phone number

Additional information for the I QUIT NOW helpline

Consent
I give permission for this form to be faxed to the I QUIT NOW helpline, so that I QUIT NOW helpline can contact me regarding my attempt to quit smoking. I understand that the I QUIT NOW helpline will keep my information confidential and will only use it for the purpose of administering the fax referral program.