quit forms

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quit forms
hi

August 31, 2009 (2 years 5 ago)
Quit smoking and use healthy herbal vaporizers. www.vapir.com

New York State Smokers’ Quitline 1 – (866) – NY – QUITS (1-866-697-8487)





Fax-to-Quit

Patient stamp, label OR Name, record number, DOB, date:









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: Ready to quit Thinking about quitting Not ready to quit



ASSIST smoker to quit: Brief counseling Prescription medications if appropriate:

Nicotine Replacement (CIRCLE): patch gum lozenge inhaler nasal spray

Other (CIRCLE): bupropion (Zyban® or Wellbutrin SR®)

ARRANGE follow-up: Refer to NYS Smokers’ Quitline by faxing this page (toll-free) to 1-866-784-8329





REFERRAL SOURCE

Name (Please print) Phone (area code + number)

Referred

by: ______________________________________________________________

( ) ________ - _______________

Group/Agency/Hospital/Organization Fax (area code + number)



______________________________________________________________ ( ) ________ - _______________

Street Address/City/State/Zip Code DO NOT CALL PATIENT UNTIL AFTER

(mm/dd/yy):

______________________________________________________________

_______ / _________ / _________



Send progress report to (If different from above):

Name (Please print) Phone (area code + number)

________________________________________________________________________________________________

Group/Agency/Hospital/Organization ( ) ________ - _______________



________________________________________________________________________________________________ Fax (area code + number)



Street Address/City/State/Zip Code ( ) ________ - _______________

________________________________________________________________________________________________





PATIENT INFORMATION

Patient’s name (Please print) Date of Birth (mm/dd/yy):



First: ___________________________ Last: __________________________________________ ______/________/________



Phone number (including area code): ( ) __________ - _________________ May we leave a message? Yes No



Best time to call: Morning (9 am to noon) Afternoon (Noon to 5 pm) Evening (5 pm to 9 pm) Language: English

Spanish

Street Address: _______________________________________________________________________ Other: _______________



Health Yes

City: _________________________________________________ Zip Code: _____________________

Insurance? No

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. Date



ReferFormRV1-05-04.doc


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