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Universal Enrollment Form

At the heart of the QuitWorks program is a generic, universally endorsed enrollment form. This universal form can be used by any provider with any patient, regardless of health insurance status. Pediatricians can also use the universal form with a child's parent or guardian if they use tobacco.

Providers in office practices and in many health care facilities should download the universal enrollment form and reproduce it for their use.

Read about special features of the QuitWorks enrollment form.

Customized Enrollment Forms for Hospitals, Health Centers and Public Health Programs

More than 50 health centers, clinics, and hospitals in Massachusetts have a customized QuitWorks enrollment form. Check below for a customized form for your facility. If you would like to customize QuitWorks for your facility, please contact us.

• Use our universal enrollment form (see above)
• Contact us.

NOTE: The enrollment forms are in PDF format. Adobe Acrobat Reader is required to view these forms and can be downloaded for free at www.adobe.com.