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? yes no Preset referral agents - None - Aspen Dental Hygiene IncAnchor MedicalArbutus MidwivesBC Cancer: Lung Screening StudyBC Lung Cancer Screening ProgramBarriere Medical ClinicBoundary Community Health CentreBridge Clinic/Raven Song Community CentreBurnaby Community Mental Health and Substance Use ServicesCBI-Specialty Clinic VictoriaCFB EsquimaltCanadian Mental Health AssociationCare4YouCastlegar Health CentreCastlegar Health CentreCowichan Lake Health UnitCrossroads Pharmacy Remedy's RxDogwood Medical ClinicElk Lake DentistryEvergreen PharmasaveFraser Medical ClinicIngram PharmacyInterior HealthIsland Pharmacy #4Jim Pattison Lung HealthKamloops Public HealthKitsumkalum Health CentreLangley Health UnitLondon Drug: CourtenayLondon Drugs #36London Drugs #73London Drugs Duncan #77London Drugs Store 061London Drugs Store 15London Drugs: Colwood CornersLondon Drugs: Nanaimo North Town CentreLondon Drugs: Nanaimo Port PlaceLondon Drugs: Saanich Centre #014Medicine Shoppe Pharmacy #169Midway Health UnitNanaimo Health UnitNanaimo Health UnitNanaimo Health UnitNanaimo Health UnitNanaimo Health UnitNanaimo Health UnitNanaimo Regional General HospitalNanaimo Regional General HospitalNanaimo Regional General HospitalNew Westminster Family PracticeNew Westminster Primary Care ClinicOceanside Integrated Health CentrePeninsula Health Unit Primary Care NP ClinicPeople's Drug Mart #123Pharmasave ParksvillePharmasave Qualicum BeachPrince Rupert Regional HospitalQuitNow Health PromotersRebalance MDRoyal Columbian HospitalRoyal Jubilee HospitalSafeway #0191Safeway #4917Safeway #4927Safeway #4944Safeway #4971-Maple RidgeShoreline Medical Brentwood BaySilvertip MineSprott Shaw CollegeSt. Paul's HospitalThrifty FoodsThrifty Foods DuncanThrifty's Foods ParksvilleUBC Dental ClinicUniversity Hospital of Northern BCVGH EDVGH Pulmonary Rehabilitation ProgramVancouver Island UniversityVancouver Island UnviersityVernon Jubilee Hospital: Cancer CentreVictoria Health CooperativeWR-SS Primary Access ClinicWRSS Primary Care NetworkWhite Clinic Associates Referral organization Referral agent type - None -DoctorPharmacistHospitalOther Referral agent first name Referral agent last name Referral agent email Referral agent phone Referral agent postal code ZIP/Postal Code Referral date 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 collection, use and disclosure of your personal information is being made in accordance the provisions of the Freedom of Information and Protection of Privacy Act, Section 26, sections c and e. Your personal information will only be stored and shared with our service providers 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. First name Last name Gender - Select -MaleFemaleTransgender female/Trans womanTransgender male/Trans manGenderqueer/Gender nonconformingOtherPrefer not to answer Year of Birth 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. Online E-mail Phone Phone number What is your prefered language - Select -AfrikaansAmharicArabicAsturianAzerbaijaniBelarusianBulgarianBengaliTibetanBosnianCatalanCzechWelshDanishGermanDzongkhaGreekEnglishEsperantoSpanishEstonianBasquePersian, FarsiFinnishFilipinoFaeroeseFrenchFrisian, WesternIrishScots GaelicGalicianSwiss GermanGujaratiHebrewHindiCroatianHaitian CreoleHungarianArmenianIndonesianIcelandicItalianJapaneseJavaneseGeorgianKazakhKhmerKannadaKoreanKurdishKyrgyzLaoLithuanianLatvianMalagasyMacedonianMalayalamMongolianMarathiBahasa MalaysiaBurmeseNepaliDutchNorwegian BokmålNorwegian NynorskOccitanPunjabiPolishPortuguese, PortugalPortuguese, BrazilRomanianRussianScotsNorthern SamiSinhalaSlovakSlovenianAlbanianSerbianSwedishSwahiliTamilTamil, Sri LankaTeluguThaiTurkishTuvanUyghurUkrainianUrduVietnameseLolspeakChinese, SimplifiedChinese, Traditional Weekdays Morning Afternoon Evening Weekend Morning Afternoon Is it OK to leave a message? Yes No Be sure to get consent from your patient prior to hitting the submit button. The patient provides consent for the referral to QuitNow for smoking cessation service. The patient provides consent for QuitNow to inform their referral agent about outcomes related to enrolment in the QuitNow program.