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Healthcare & Partners

Online Referral Form

Any healthcare provider or allied health professional in Manitoba, Ontario and Saskatchewan can refer their First Nation, Inuit, or Métis clients to Talk Tobacco by:

Online: Complete and submit the form below

Print: Download the referral form here, print, complete and email to or fax to 1-877-513-5334

Web fillable: Complete the form online here, save and email to

Healthcare provider information

Patient/client information

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

Time of day

Consent to contact: