| Special
Instructions |
|
Sharing
the Form with Clinicians |
|
Referring
Your Clients to the Quit Line
|
| Sharing
the Form with Clinicians |
| 1. |
Before
providing the form to clinicians, obtain their clinic
name, fax number and phone number, as well as the name
of the person at the clinic who will act as a contact
person for the Quit Line if ever necessary.
|
| 2. |
Type
in the clinic name, fax number, phone number and contact
person into the appropriate spaces BEFORE giving the form
to the clinic. This prevents problems related to incomplete
or illegible forms. Provide the clinician with both the
English and Spanish forms, so that clinicians can serve
both their English-speaking and Spanish-speaking clients.
|
| 3. |
Provide
clinicians with the instructions for using the Utah Tobacco
Quit Line Proactive Fax Referral System when you give
them the form. The instructions are on The Utah Tobacco
Quit Line Proactive Fax Referral System page.
|
| 4. |
After
initial receipt of the personalized form, it is the
health care provider’s responsibility to make
copies for future use.
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to Top
|
| Referring
Your Clients to the Quit Line |
Local
Health Departments may also use the proactive fax referral
system to refer LHD clients to the Utah Tobacco Quit
Line. To adapt the form for this purpose, you
will need to type in the name of the local health department,
followed by the program within the local health department,
in the space labeled "clinic name". For example,
"Clinic Name: Davis County Health Department, WIC"
or "Clinic Name: Tri-County Health Department,
Health Promotion".
|
| |
The
Utah Tobacco Quit Line Proactive Fax Referral System
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to Top
|
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