Fax this completed form to: 03 6169 1941 					       quittas.org.au
HealthLink Identifier/EDI: quittasx

Referrer Details
Name	<<Doctor:Name>>	
Organisation	<<Practice/Location:Name>>	
Telephone	<<Practice/Location:Phone>>	
Fax	<<Practice/Location:Fax>>	
Email	<<Practice/Location:E-mail>>	

Client Details
Name	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	
Preferred Phone No.	<<Patient Demographics:Phone (Mobile)>>	

Notes:

Privacy is important to us and we treat your information with respect, integrity and honesty in keeping with our core values and as governed by the Privacy Act. Personal information is only collected as necessary for agreed Quit programs or activities. Our full Privacy Policy may be accessed here http://www.cancertas.org.au/privcacy-statement/