Quitline Fax Referral Form


A HIPPA compliant fax referral form used by healthcare providers or community members to secure prospective quitter’s consent to have the Arkansas Tobacco Quitline (ATQ) get in touch with him or her. The form contains required information from the tobacco user and once complete and submitted to the ATQ, the individual will be contacted to begin the enrollment process. The fax referral form is available in English and Spanish for printing or ordering. An electronic method for referral is also available at https://arkansas.quitlogix.org/.


Download for Printing