Get Fax-to-quit Referral Form Referred By - Wvde State Wv
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How to fill out the FAX-TO-QUIT Referral Form Referred By - Wvde State Wv online
This guide provides step-by-step instructions to assist users in completing the FAX-TO-QUIT Referral Form Referred By - Wvde State Wv. The information provided will help ensure accurate submissions for effective communication with the West Virginia Tobacco Quitline.
Follow the steps to successfully fill out the form online.
- Press the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
- In the 'Referred By' section, select your relationship to the participant by checking the appropriate box, such as Coach, Teacher, or any other relevant title. If your role is not listed, fill in the 'Other' option with the specific title.
- In the Participant Consent and Personal Information section, ensure that the participant understands that their information will be used confidentially. The participant should print their name clearly in the designated space.
- If a signature from the participant is available, it should be signed in the 'Participant or Guardian Signature' area. If there is no signature, you need to indicate that verbal consent was obtained, providing the name of the person who received it.
- Fill in the participant's date of birth in the specified format (MM/DD/YYYY), followed by their county of residence.
- Enter the participant's phone number, selecting the appropriate type as Home, Work, or Cell. Provide the best possible time for the Quitline to contact the participant.
- Indicate whether a message can be left by the Quitline representative during the provided phone call times, selecting 'Yes' or 'No'.
- Complete the Quitline use section by noting if the participant was enrolled or if they could not be reached. Fill out the date accordingly.
- Once all fields are completed, review the information for accuracy. Save the changes, download, print or share the completed form as necessary.
Complete your FAX-TO-QUIT Referral Form online today for effective assistance in quitting tobacco.
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Writing a referral form involves several key steps: clearly state the purpose, include necessary details about the person being referred, and mention the recommended service or program. Ensure the information is accurate and comprehensive, making it easier for the receiving party to assess the individual's needs. Utilizing the FAX-TO-QUIT Referral Form Referred By - Wvde State Wv can simplify this task, allowing you to meet all requirements effectively.
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