Oregon Tobacco Quit Line Referral Form



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




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





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