About the Fax Referral Systems
Some people are uncomfortable initiating contact with the Quit Services and others simply lose the phone number before they have an opportunity to call. Now, clinicians can directly refer clients using the Utah Tobacco and Nicotine Quit Services Fax Referral System. The Utah Tobacco and Nicotine Quit Services proactively calls your clients to help them quit.
Fax Referrals
- Download the Fax Referral Form.
- Print the form and photocopy it. Make enough copies for each of your clients who use tobacco to have their own form.
- Ask your tobacco-using clients if they would like the Utah Tobacco and Nicotine Quit Services to help them quit. If a client would like help, write your name on the form and ask the client to fill out the rest of the form. The client must sign the form or, if the client is a minor, the client’s guardian must sign the form. If the client does not want to fill out the form, give the patient Quit Service’s toll-free telephone number 1.800.QUIT.NOW (1-800-784-8669) or offer a card so that the patient can contact Quit Services when they are ready. Do not pressure patients to fill out the form if they do not want to.
- When the client finishes filling out the form, verify that all items are filled in, that the handwriting is legible and that the mandatory signature is present.
- Fax the form to the Utah Tobacco and Nicotine Quit Services’ toll-free fax number: 1-800-483-3076.