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 talktobacco@cancer.ca or fax to 1-877-513-5334

Web fillable: Complete the form online here, save and email to talktobacco@cancer.ca

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.

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.