Register to Become a QuitlineNC Referral Site

Submitted by kzachary on

Thank you for helping your patients/clients to become tobacco-free. Please complete this one-time registration form for your site and then start making referrals!

For current referral sites: Update your registration

Get Started 

  • About Your Site
  • The People You Serve
  • Contact Information
  • Complete
Indicates required field
Is this site part of a larger health care/behavioral health organization or system?
Mailing Address
County/Counties Your Site Serves
Types of Medical Sites
Types of Behavioral Health Sites
Indicate how your clinic currently sends referrals.
Is your clinic/practice/agency HIPAA compliant?