ITQL - Agency Enrollment

AGENCY ENROLLMENT
1-866-QUIT-YES

1-866-784-8937

Tobacco Treatment Enrollment Form

PARTICIPANT INFORMATION

PARTICIPANT CONSENT

I authorize my provider to release the information on this referral form to the Illinois Tobacco Quitline (ITQL) for purposes of my participation in the tobacco cessation program. I also authorize the ITQL and its representatives to contact me at the phone number(s) and/or email listed above. I give the ITQL permission to discuss my use of service.

Please check the box to provide your consent.

REFERRAL AGENCY

Agency Name

This field is required.

Contact Name

This field is required.

Contact Number

This field is required.

Today's Date

This field is required.

1-866-784-8937 Tobacco Treatment Enrollment Form

1-866-784-8937

Tobacco Treatment Enrollment Form