Refer your clients for proactive phone support

Any healthcare provider or allied health professional in SK, MB, PE or YT can refer their clients to Smokers’ Helpline using the online referral form below or by fax at 1-866-641-7675 using a Quit Connection referral form. In Ontario, clients can be referred to Telehealth Ontario's Smoking Cessation service via this online form or the Telehealth Ontario referral form which may be faxed to 1-888-857-6555 or 519-434-9028. Minimal contact intervention is quick, easy and effective and Smokers’ Helpline will do the rest.

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
  • Order or download promotional materials and support tools
  • Before submitting, print the completed page and file the referral form with your client’s chart

Healthcare provider information

Patient/client information

Smokers' Helpline usually calls within 3 business days. When should we call?

Time of day

Consent to contact: