For use by health professionals to refer patients to the Quitline.
Mandatory fields are marked with an *
Patient Information - CONFIDENTIAL
Phone (one of)* - Home
Preferred Contact Number*
What is the best time for the Quitline to call?*
Does your patient identify as Aboriginal or Torres Strait Islander?*
By submitting this referral you acknowledge that your patient has consented to this information being disclosed.
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