Quitline Referral Form

Quitline Free NRT Referral Form

To refer a patient or client to Quitline, simply complete the Free NRT Referral Form below or download it here: Quitline Free NRT Referral Form.

For further information or enquiries email admin@quittas.org.au or phone (03) 6169 1943.

Organisation / School / Medical Practice Name*
Name of person referring*
Phone*
Fax
Email*
Client Details
Name*
Preferred phone number*
Gender
Year of Birth
Available to those who are: (tick those applicable)
- Youth (12-25 years)
- Aboriginal and Torres Strait Islander
- Pregnant and/or their partner
- Parents of a child aged 0-12 months
- Eligible for the National Lung Cancer Screening Program
Smoking/Vaping status
- Smoking
- Vaping
- Dual user
Notes (eg: health concerns)
Consent*
I have acknowledged the privacy policy.
Privacy is important to us and we treat your information with respect, integrity and honesty in keeping with our core values and as governed by the Privacy Act. Personal information is only collected as necessary for agreed Quit programs or activities. Please visit our Privacy Statement. If you have any queries please don’t hesitate to contact us on 03 6169 1943 or by email admin@quittas.org.au
The above question is for testing whether you are a human visitor and to prevent automated spam submissions.
The above question is for testing whether you are a human visitor and to prevent automated spam submissions.