The Illinois Tobacco Quitline 1-866-QUIT-YES

Tobacco Treatment Enrollment Form

Required fields are in BOLD.

   PATIENT INFORMATION
First Name
Last Name
Mailing Address
City
State
ZIP
Email Address
Gender
Female Male
Pregnant?
No Yes
Date of Birth
/ /
Ethnicity
Phone Number
Alternate Phone
When should we call?
(CST)
May we leave a message?
Yes  No
Language Preference 
English  Spanish  Other (Specify):

   PATIENT SIGNATURE
By checking this box, the patient's gave verbal consent to authorize their provider authority to release the information on this enrollment form to the Illinois Tobacco Quitline for purposes of my participation in the tobacco cessation program. I also authorize the Illinois Tobacco Quitline and its representatives to contact me at the phone number(s) I have listed above upon receiving this referral from my provider. I give the Quitline and the referring agency permission to discuss my use of service.

HEALTHCARE PROFESSIONAL         TOBACCO TREATMENT CHECKLIST
1. ASK about use
Identify and document patient's tobacco use
2. ADVISE to quit
In a clear, strong personalized manner, urge patient to quit.
3. ASSESS readiness to quit
Is patient willing to make an attempt?
4. ASSIST in quit attempt
Suggest counseling or pharmacotherapy to assist in quit.
5. ARRANGE follow up
By faxing this form, the Illinois Tobacco Quitline will follow-up.
ASSESSMENTof readiness to quit   
ASSISTANCE to quit   Amount of Tobacco Use:
Additional Comments:
Sub Program   
Clinic Code   

 

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