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Quitline 13 7848
Quitline 13 7848
Referral Form

Quitline Client 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.

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

* NB: THIS FORM IS ONLY FOR HEALTH PROFESSIONALS AND COMMUNITY WORKERS REFERRING THEIR CLIENTS* 

  • Referrer Information

  • Client Information

  • The above question is for testing whether you are a human visitor and to prevent automated spam submissions.