Update Your QuitlineNC Referral Site Registration

Submitted by kzachary on

Please complete this form to update your QuitlineNC Referral Site's registration. Thank you for helping your patients/clients to become tobacco-free. 

Trying to register? Register to Become a QuitlineNC Referral Site

Get Started 

Indicates required field
What information do you need to update? (Check all that apply)
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?
If unsure, indicate your best estimate.
We'll send a copy of your submission form to you.