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

Provider Web Referral

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

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.