Provider Web Referral

Provider Web Referral

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

eReferral

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

Fax referral

To refer your patient, please click on the link to access the referral form.