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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.
Download Customized Enrollment Forms
- Hospitals
- Anna Jacques Hospital
- Caritas Christi Health Care
- Franklin Medical Center
- Harrington Hospital
- Holyoke Medical Center
- Lowell General Hospital
- Marlborough Hospital
- Massachusetts General Hospital
- MetroWest Medical Center
- Noble Hospital
- North Shore Medical Center
- Southcoast Hospitals Group
- Tufts New England Medical Center
- UMass Health Alliance
- UMass Memorial - English
- UMass Memorial - Spanish
- Wing Memorial
- Health Centers
- Chicopee Health Center
- Dimock Center
- Family Health Center of Worcester
- Great Brook Valley Health Center
- Greater Lawrence Family Health Center - English
- Greater Lawrence Family Health Center - Spanish
- Greater New Bedford Community Health Center
- Harvard Vangard Medical Associates - Middle Earth
- Harvard Vangard Medical Associates - North
- Harvard Vangard Medical Associates - South
- Harvard Vangard Medical Associates - Urban
- Island Health Care
- Joseph M. Smith Community Health Center
- Lowell Community Health Center - English
- Lowell Community Health Center - Spanish
- Manet Community Health Center
- Mattapan Community Health Center
- MGH-Revere Healthcare Center
- RoxComp Community Health Center
- Public Health Programs
- Hospitals
Not Listed?
- Use our universal enrollment form (see above)
- View the forms in an alphabetical list
- 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.
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