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Get WV Tobacco Quitline Fax-to-Quit Referral Form 2015-2024

On, please print clearly. Provider Name Clinic/Hospital/Organization Address City/State/Zip Contact Name Phone Fax Email Please check box if the patient has any of the following conditions: Pregnant Irregular Heartbeat Recent Heart Attack (within the last two weeks) If any box above is checked, please sign to authorize the WV Tobacco Quitline to send the patient free, over-thecounter nicotine replacement therapy. If provider does not sign and the patient has any of the above lis.

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