Home

Quit Smoking

Self Referral to Quitline

Indicates Mandatory Fields

Quitline is a confidential service, all information provided remains confidential.

Name:
Sex:	Male Female
Date of Birth: (dd/mm/yyy)
Postal Code:
Are you of Aboriginal and Torres Strait Islander origin?
Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander No
Are you of Australian South Sea Islander origin?
Yes No
Contact phone number:	(please provide the best phone number for the contact at the time of the requested call)
Email address:
Preferred contact time: (tick all that apply)
7am - 9am 9am - 12pm 12pm - 5pm 5pm-8.30pm 8.30pm - 10pm
Preferred day of the week: (tick all that apply)
Mon Tues Wed Thur Fri Sat Sun
Is it ok to leave a message?
Yes No
Contact requirements
Translating and Interpreting Service (please specify language ) National Relay Service Female staff member preferred Male staff member preferred Aboriginal and/or Torres Strait Islander staff member preferred Other (please specify )
Health information (please select all applicable)
Diabetes Type 1 Diabetes Type 2 Heart Disease Respiratory Disease Pregnant/breastfeeding Epilepsy Anxiety Depression
Notes