Provider Web Referral

For Patients Without NRT Contra-indications
Complete the Provider Web Referral. You don’t need to print any pages.


For Providers Interested in using eReferral
Please submit our Contact Us form to learn more about our eReferral program.

Fax referral

For Patients With NRT Contra-indications
If a patient has contra-indications to using NRT, please print, sign and return a Fax Referral form.