Request a callback

    Please complete the form below and a member of the Help Me Quit contact centre team will call your patient/client within 72 hours.

    Please note, prescription only medications such as Zyban and Champix are not currently available.

    Client / patient details:

    If your client/patient is currently in hospital, please provide:










    Consent to be contacted by text:

    YESNO




    Referrers details: