eReferral 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.