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This form is used to refer individuals interested in free counseling and nicotine replacement therapy through the Vermont Quit Network.
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How to fill out vermont quit network referral
How to fill out Vermont Quit Network Referral Form
01
Visit the Vermont Quit Network website.
02
Download the Quit Network Referral Form.
03
Fill in the personal details of the individual seeking help, including name, address, phone number, and email.
04
Provide relevant information about the individual's smoking history and readiness to quit.
05
Include any additional comments or notes that may be helpful for the Quit Network team.
06
Review the completed form for accuracy.
07
Submit the form via the specified method (online, email, or mail).
Who needs Vermont Quit Network Referral Form?
01
Individuals looking to quit smoking or using tobacco products.
02
Healthcare providers referring patients to cessation resources.
03
Organizations or community groups assisting members with quitting tobacco.
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What is Vermont Quit Network Referral Form?
The Vermont Quit Network Referral Form is a document used to refer individuals who wish to quit smoking or using tobacco products to support services provided by the Vermont Quit Network.
Who is required to file Vermont Quit Network Referral Form?
Health care providers, organizations, or agencies that interact with individuals looking to quit tobacco may be required to file the Vermont Quit Network Referral Form.
How to fill out Vermont Quit Network Referral Form?
To fill out the Vermont Quit Network Referral Form, individuals must provide the necessary information including the referent's details, the person's contact information, and additional relevant health information.
What is the purpose of Vermont Quit Network Referral Form?
The purpose of the Vermont Quit Network Referral Form is to facilitate the connection between individuals who want to quit smoking or using tobacco and the resources available through the Vermont Quit Network for support and assistance.
What information must be reported on Vermont Quit Network Referral Form?
The information that must be reported on the Vermont Quit Network Referral Form includes the referrer’s name and contact information, the individual’s name, contact information, tobacco use history, and any relevant medical or social information.
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