Universal Referral Form

At the heart of the QuitWorks-NH program is a generic, universally endorsed referral form.

This universal form can be used by any provider with any patient, regardless of health insurance status. Pediatricians can also use the universal form with a child's parent or guardian if they use tobacco.

Providers in office practices and in many health care facilities should download the universal enrollment form and reproduce it for their use.

Read about special features of the QuitWorks-NH referral form.

Customized Referral Forms for Hospitals, Health Centers and Public Health Programs

Many health centers, clinics, and hospitals in New Hampshire have a customized QuitWorks enrollment form. Check below for a customized form for your facility. If you would like to customize QuitWorks for your facility, please contact us.

• City of Manchester Health Department
  Select a formNettletonRouleau
• City of Nashua Health Department
  Select a form Dembkoski
• Community Action Program Belknap and Merrimack Counties
  Select a formDulacThompson
• Dartmouth-Hitchcock, Manchester, Tobacco Dependence Treatment Center
• VNA-Hospice of Southern Carroll County & Vicinity

NOTE: The referral forms are in PDF format. Adobe Acrobat Reader is required to view these forms and can be downloaded for free at www.adobe.com.