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.
What services do patients receive?

A Cessation Counsellor will initiate a call to your patient based on their preferred availability. Patients interested in quitting will be enrolled in the program and will receive at least five counselling and follow-up sessions, including:

  • Development of a personalized quit plan
  • Help with learning new skills and behaviours
  • Information about pharmacotherapy options
  • Calls on quit date and post-quit dates for support

Note: Once the program ends, patients are encouraged to call back at any time for on-going support or relapse prevention.