Healthcare & Partners

Online Referral Form

Any healthcare provider or allied health professional in British Columbia, Manitoba, Ontario and Saskatchewan can refer their First Nation, Inuit, or Métis clients to Talk Tobacco by:

Online: Complete and submit the form below

Print: Download the referral form here, print, complete and email to talktobacco@cancer.ca or fax to 1-877-513-5334

Web fillable: Complete the form online here, save and email to talktobacco@cancer.ca

Healthcare provider information

First name*

Last name*

Email*

Postal code*

Telephone*

Organization*

Department

Position*

Patient/client information

First name*

Last name*

Birthdate*

Gender*

Province*

Postal code*

Telephone*

Language(s)*

This question is voluntary.
Does the patient/client identify as First Nations, Inuit, Métis or Indigenous? We offer culturally sensitive cessation counselling to Indigenous clients if the client self-discloses this information.

If yes, the patient/client referral will be referred to Talk Tobacco, a free Canadian Cancer Society confidential program offering culturally appropriate support and information about quitting smoking, vaping and commercial tobacco use to First Nations, Inuit, Métis and urban Indigenous communities.

A Quit Coach usually calls within 3 business days. When should we call?

Morning
Afternoon
Evening
Anytime

Consent to contact:

Additionally, by checking the box, I confirm I’ve obtained consent from my patient/client to submit this referral on their behalf to either Smokers Helpline (SHL) or, if my patient/ client is Indigenous, to Talk Tobacco. I acknowledge that I have informed the patient/ client that a Quit Coach will contact them directly regarding his or her attempt to quit or reduce smoking or vaping. I have explained the purpose of the disclosure of the information to the patient/client and have advised the patient that SHL or Talk Tobacco may use the information to communicate directly with the referring health care provider. I informed the patient that SHL and Talk Tobacco will keep all information confidential and will only use it for the purposes outlined below. Patient must be made aware that the Canadian Cancer Society (CCS) collects personal information to manage their participation in the program, inform them about other services and contact them to provide updates about CCS’s impact and ways to support CCS or give. CCS may also use their information for program evaluation and quality assurance. CCS may share their personal information with third parties including service providers, consultants and advisors outside their province or territory or outside of Canada only to carry out the purposes identified above, or as required by law. CCS may contact them by mail, email, phone or text. They can exercise their right to access your information or have it corrected, unsubscribe from communications or withdraw their consent by calling 1-888-939-3333 or emailing privacy@cancer.ca. For more information about CCS’s privacy practices, visit cancer.ca/privacy.

Privacy Disclosure:
We collect your personal information through forms, by phone or in person to manage your participation in the program, inform you about other services and contact you to provide updates about our impact and ways to support us or give. We may also use your information for program evaluation and quality assurance. We may share your personal information with third parties including service providers, consultants and advisors outside your province or territory or outside of Canada only to carry out the purposes identified above, or as required by law. We may contact you by mail, email, phone or text. You can exercise your right to access your information or have it corrected, unsubscribe from communications or withdraw your consent by calling 1-888-939-3333 or emailing privacy@cancer.ca. For more information about our privacy practices, visit cancer.ca/privacy.

About Talk Tobacco

Healthcare & Partners

Online Referral Form

Healthcare provider information

Patient/client information

A Quit Coach usually calls within 3 business days. When should we call?

Consent to contact: