Make a referral

Patient Information for Referral

Please be sure that your patient has provided consent for you to disclose their personal information to QuitNow. They should be made aware of the following privacy statement:

The information on this form is being collected under the Freedom of Information and Protection of Privacy Act 26 (c) & (e) and will be used to provide smoking cessation services to you and for ongoing research and program evaluation of our services. For more information regarding the collection, use and disclosure of your personal information please contact the Privacy Officer, British Columbia Lung Association, PO Box 34009 Station D, Vancouver, British Columbia, V6J 4M2, privacy.officer@bc.lung.ca, 1-800-665-5864

Gender

Services Requested

We will do our best to make contact with your patient for the requested service. For a number of reasons we can have difficulty making successful contact. Ensuring correct contact information is most helpful.

Referral Source

An agent is the person who is completing the online referral with the consent of and on behalf of the patient/smoker.

Agent's first referral?
Be sure to get consent from your patient prior to hitting the submit button