Asian Smokers' Helpline: 1-800-838-8917/1-800-556-5564/1-800-778-8440

ASQ Web Referral Registration

If your parent or referring organization is not listed below, please visit our registration page here.

1. Provider Information

Parent or Umbrella Organization :
Referring Organization :
Title:
Provider First Name:
Provider Last Name:

2. Patient Information

First Name :
 
Last Name :
 
Date of Birth :
 /  /      
Phone :
 
Alternate Phone :
 
Language :




State of residence:
Gender:



3. Patient Consent

Please read the following to the patient or parent/guardian of the patient and check the box to indicate that the patient provides consent:
I give my permission for the above-named organization to share my (or my child's) contact information with the Asian Smokers' Quitline.
I give the Quitline permission to contact me (or my child) to provide help to quit smoking or other tobacco.
Type the code from image: