quit forms

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August 31, 2009 (2 months 27 days ago)
Quit smoking and use healthy herbal vaporizers. www.vapir.com

New York State Smokers’ Quitline 1 – (866) – NY – QUITS (1-866-697-8487) Patient stamp, label OR Name, record number, DOB, date: Fax-to-Quit Fax Referral Form Fax form to: 1-866-QUIT-FAX (1-866-784-8329) TOBACCO TREATMENT CHECKLIST ADVISE smoker to stop smoking. Recommended stop-smoking advice: “I strongly advise you to quit smoking and can help you.” ASSESS readiness to quit: ASSIST smoker to quit: Nicotine Replacement (CIRCLE): Other (CIRCLE): ARRANGE follow-up: Ready to quit Brief counseling patch bupropion gum (Zyban® Thinking about quitting lozenge inhaler or Wellbutrin SR®) Not ready to quit nasal spray Prescription medications if appropriate: Refer to NYS Smokers’ Quitline by faxing this page (toll-free) to 1-866-784-8329 REFERRAL SOURCE Referred by: Name (Please print) Phone (area code + number) ( ) ________ - _______________ ______________________________________________________________ Group/Agency/Hospital/Organization Fax (area code + number) ( ) ________ - _______________ ______________________________________________________________ Street Address/City/State/Zip Code ______________________________________________________________ Send progress report to (If different from above): Name (Please print) ________________________________________________________________________________________________ Group/Agency/Hospital/Organization ________________________________________________________________________________________________ Street Address/City/State/Zip Code ________________________________________________________________________________________________ DO NOT CALL PATIENT UNTIL AFTER (mm/dd/yy): _______ / _________ / _________ Phone (area code + number) ( ) ________ - _______________ Fax (area code + number) ( ) ________ - _______________ PATIENT INFORMATION Patient’s name (Please print) First: ___________________________ Phone number (including area code): Best time to call: Street Address: ( Last: __________________________________________ ) __________ - _________________ Afternoon (Noon to 5 pm) Date of Birth (mm/dd/yy): ______/________/________ Yes No English May we leave a message? Language: Morning (9 am to noon) Evening (5 pm to 9 pm) _______________________________________________________________________ Zip Code: _____________________ Spanish Other: _______________ Health Insurance? Yes No City: _________________________________________________ E-mail: _______________________________ Insurance carrier: ____________________________________________ If Medicaid, ID Number: _______________________________________ @ ________________________ . __________ PERMISSION I (undersigned) give permission for the support staff of the New York State Smokers’ Quitline to contact me, coach me in quitting smoking, and give feedback regarding my progress to the health care provider listed above and permission for that provider to forward the information to other relevant health care providers. ________________________________________________________________________________________________________ Signature of Patient (or Agent if authorization was verbal). Signature is required for patient to be called. ReferFormRV1-05-04.doc _____/_____/_____ Date

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