Quit Tobacco Resources For Professionals and Healthcare Providers About the Helpline



How much does smoking cost you?

How many cigarettes are you really smoking?

Register with the QuitFax Referral System

Name: Title:
First Name:  MI:
Last Name:
Position Title:
Business Name:
Address: Street:
City:
State: AZ Zip:
Contact: Phone:   
Fax:
E-mail:
Medical Specialty:
Which best describes your business: Private physician's office
Healthcare clinic
Managed care organization
Hospital
WIC clinic
College or university health center
School-based clinic (K-12)
Other, describe:
Would you like more information: Helpline Services
Community-based Services
Web Services
Healthcare Provider Training
Basic Intervention Training
QuitFax Referral Program
Would you like future information updates? Yes   No