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Smokers Helpline Fax: 1 877 5135334 Smoking Cessation CONFIDENTIAL Program Referral Form HEALTHCARE PROVIDER REFERRAL SOURCE REQUIRED PLEASE PRINT PLEASE PRINTHealthcare Provider (select one) Dental
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How to fill out smoking cessation referral forms

01
Step 1: Obtain the smoking cessation referral form from the appropriate healthcare provider or facility.
02
Step 2: Fill out the patient's personal information including name, date of birth, contact information, and insurance details.
03
Step 3: Provide information on the patient's smoking history, including frequency, duration, and any previous quit attempts.
04
Step 4: Indicate the reason for the referral, such as desire to quit smoking, health concerns, or recommendation from healthcare provider.
05
Step 5: Sign and date the form to certify the information provided is accurate and complete.
06
Step 6: Submit the completed form to the designated recipient or healthcare provider for processing.

Who needs smoking cessation referral forms?

01
Individuals who are looking to quit smoking
02
Patients who have expressed interest in smoking cessation programs
03
Healthcare providers who want to refer patients to smoking cessation resources
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Smoking cessation referral forms are documents used to refer individuals who want to quit smoking to specialized programs or services for support and guidance.
Healthcare providers, counselors, or other professionals who are assisting individuals in quitting smoking may be required to file smoking cessation referral forms.
To fill out smoking cessation referral forms, one must provide information about the individual seeking help to quit smoking, including their personal details, smoking history, and any relevant medical information.
The purpose of smoking cessation referral forms is to connect individuals who want to quit smoking with the necessary resources and support to help them successfully quit.
Information such as the individual's name, contact information, smoking habits, medical history, and any specific needs or preferences for smoking cessation programs may need to be reported on the forms.
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