Healthcare & other partners

Smoking cessation is your most powerful preventative health intervention. You can make a difference. Smokers' Helpline can help.

Refer your clients for proactive phone support

Any healthcare provider or allied health professional in Saskatchewan, Manitoba, Prince Edward Island or Yukon can refer their clients to Smokers’ Helpline using the online referral form below or by faxing a Quit Connection PDF referral form to 1-877-513-5334.

First Nation, Inuit, Métis and urban Indigenous clients

Any healthcare provider or allied health professional in Manitoba, British Columbia, Ontario and Saskatchewan can refer their First Nation, Inuit, Métis or urban Indigenous clients to Talk Tobacco.

Ontario

Phone support in Ontario is provided by the Health811 Ontario Smoking Cessation Program. Clients can be referred to the service by faxing the Health811 Ontario referral form to 1-877-356-1691.

Tips for making successful referrals:

Make a cessation intervention a systematic part of your care
Keep this referral form bookmarked or printed forms accessible and fully stocked
Photocopy the form with your contact information already filled out
Contact us to order promotional and support materials such as referral forms and Talk Tobacco referral cards
Before submitting, print the completed page and file the referral form with your client’s chart

Healthcare provider information

First name*

Last name*

Email*

Postal code*

Telephone*

Organization*

Department

Position*

Patient/client information

First name*

Last name*

Birthdate*

Gender*

Province*

Postal code*

Telephone*

Language(s)*

Does the patient/client identify as First Nations, Inuit, Métis or Indigenous? We offer culturally sensitive cessation counselling to Indigenous clients if the client self-discloses this information.

If yes, the patient/client referral will be referred to Talk Tobacco, a free Canadian Cancer Society confidential program offering culturally appropriate support and information about quitting smoking, vaping and commercial tobacco use to First Nations, Inuit, Métis and urban Indigenous communities.

A Quit Coach usually calls within 3 business days. When should we call?

Morning
Afternoon
Evening
Anytime

Consent to contact:

By checking the box, I confirm I’ve obtained consent from my patient/client to submit this referral on their behalf to either Smokers Helpline (SHL) or, if my patient/client is Indigenous, to Talk Tobacco. I acknowledge that I have informed the patient/client that a Quit Coach will contact them directly regarding his or her attempt to quit or reduce smoking or vaping. I have explained the purpose of the disclosure of the information to the client and have advised the client that SHL or Talk Tobacco may use the information to communicate directly with the referring health care provider. I informed the client that SHL and Talk Tobacco will keep all information confidential and will only use it for the purpose of administering the referral. Patient must be made aware that CCS collects personal information to manage their participation in the program, inform them about other services and contact them to provide updates about CCS’s impact and ways to support CCS or give. CCS may also use their information for program evaluation and quality assurance. CCS may share their personal information with third parties including service providers, consultants and advisors outside their province or territory or outside of Canada only to carry out the purposes identified above, or as required by law. CCS may contact them by mail, email, phone or text. They can exercise their right to access your information or have it corrected, unsubscribe from communications or withdraw their consent by calling 1-888-939-3333 or emailing privacy@cancer.ca. For more information about CCS’s privacy practices, visit cancer.ca/privacy.

Privacy Statement

We collect your personal information through forms, by phone or in person to manage your participation in the program, inform you about other services and contact you to provide updates about our impact and ways to support us or give. We may also use your information for program evaluation and quality assurance. We may share your personal information with third parties including service providers, consultants and advisors outside your province or territory or outside of Canada only to carry out the purposes identified above, or as required by law. We may contact you by mail, email, phone or text. You can exercise your right to access your information or have it corrected, unsubscribe from communications or withdraw your consent by calling 1-888-939-3333 or emailing privacy@cancer.ca. For more information about our privacy practices, visit cancer.ca/privacy.