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

(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

 

 

 

 

© 2005 Free & Clear, Inc. All rights reserved.

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