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 smoking cessation specialists working at the I QUIT NOW quitline will be receiving all completed forms and will present all I QUIT NOW services to the patient : Telephone support offered by the I QUIT NOW quitline, Online support offered by the I QUIT NOW website, In-person support offered by the Quit Smoking Centres of their region, Text message support offered by the SMAT. Patient availability Morning: 9am to noon Afternoon: 1pm to 5pm Evening - Monday to Thursday: 6pm to 9pm Evening - Friday: 6pm to 8pm Anytime Patient gender - Sélectionner -ManWomanOther*Prefer not to answer If other please specify Patient first name Patient last name Patient phone number Language - Sélectionner -FrenchEnglish Health Care Provider - Sélectionner -DoctorNurse Respiratory therapistDentistDental hygienistPharmacistOptometristSocial workerOther If other please specify 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.