referrals

Referral Page

Getting a referral by a health care professional (e.g.
physician, dentist, chiropractor, psychotherapist, etc) is
easy. Simply call your doctor and refer them to this
page or print out the referral page below and bring or
fax it to their office. Most doctors will not charge you to
fill out the form.

	Referral For Smoking Cessation Program

		Date:

		Referring Doctor's Name:

		Office Street Address, Ste :

		City, State, Zip:

		Phone:

		Email:

		Patient Name:

		This letter is to refer the above named patient to a smoking cessation specialist
*