Patient reference form from pharmacies


Reference from pharmacies


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.
1 + 17 =
Trouvez la solution de ce problème mathématique simple et saisissez le résultat. Par exemple, pour 1 + 3, saisissez 4.