Oregon Tobacco Quit Line Referral Form

Submit signed form to the Oregon Tobacco Quit Line via Mail or Fax:

Mail: FREE & CLEAR, Inc. Fax Number: 1-800-483-3114

Attn: Support Services

999 Third Avenue, Suite 2100

Seattle, WA 98104

Date: _______/_______/_______

Referring Agency: _________

Contact Name: _________

Client Information:

Name: ______________ __________ DOB: ______/______/_____

Address: ____________ City: __ Zip: _________

Phone Number: (_____) _____ – ______________ Type (circle one): Home/Work/Cell/Other

Language Preference (check one): _____ English _____ Spanish _____ Other ____________________

______ I am ready to quit tobacco and request the Quit Line contact me to help me with my quit plan/they may leave a message

(Initial)

Signature: ________________ Date: _____/______/______

The Oregon Tobacco Quit Line will call you. Please check the BEST 3-hour time frame for them to reach you. NOTE: The Quit Line is open 7 days a week; call attempts over a weekend may be made at times other than during this 3-hour time frame.

q 5am – 9am q 9am – 12pm q 12pm – 3pm q 3pm – 6pm q 6pm – 9pm q 9pm – 12am

Confidentiality Notice: This facsimile contains confidential information. If you have received this facsimile in error, please notify the sender immediately by telephone and confidentially dispose of the material. Do not review, disclose, copy, or distribute.

Updated June 2010