Aboriginal Quitline Referral Form

Using a service like Quitline can greatly increase a person’s chance of quitting successfully.

To refer a patient or client to Quitline, simply complete the Referral Form below or download the Quitline Referral Form. Download

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

Referring organisation
Name of organisation referring*
Name of person referring*
Phone*
Fax
Email*
Client Details
Name*
Preferred phone number*
Notes
(eg: ATSI status, health concerns, pregnancy, etc)
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.