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 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
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.