Order Form for Physicians
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“Your Guide to a Smoke Free Future” booklet (40 per order)
Triage for Smoking (5 per order)
Initial Assessment of Smoking (40 per order)
Smoking Progress Notes (40 per order)
Conditions Caused by Smoking (40 per order)
Role of Medical Office Staff (5 per order)
Minimal Intervention/Stepped Care Model (5 per order)
The 'Why' Test (40 per order)
“Quit Plan” pad, 50 sheets/pad (1 per order)
Stop Smoking Medications Factsheet (40 per order)
200 mixed labels for medical records (1 set per order)
200 "smoker" labels for medical records (1 set per order)
Physician's Last Name
First Name
Street Address
Town/City
Postal Code
Phone Number
Fax Number (optional)
Email Address
You must complete all required fields to register your order.
Your privacy is important to us. Some information you provide in this order form may be considered personal information. This information will be collected, used and shared for the sole purposes of processing your order and delivering Clinical Tobacco Intervention services, programs and publications to you.
Thank you for participating in the CTI Program.
This program is funded, in part by the Government of Ontario.
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