Fax Referral Form

What is it?

A program designed to make it easy for health care providers to refer their patients/clients to AlbertaQuits Helpline for assistance to quit smoking.

2 Easy Steps!

The program connects your patient, who is willing to quit, with a Cessation Counsellor at AlbertaQuits Helpline.

  1. Download the Fax Referral Form and review with your client the best time to be called at home prior to faxing it in.
  2. Fax the form to AlbertaQuits Helpline at 1.866.979.3553 for direct follow-up with your patient.