Nebraska Tobacco Quitline - Order Form printable pdf download

Nebraska Tobacco Quitline – Order Form

Complete this form and send to one of the following:

• Email:

dhhs. n@nebraska.gov

• Fax: 402-471-6446

• Mail: Nebraska Tobacco Quitline

301 Centennial Mall S., P.O. Box 95026

Lincoln, NE 68509-5026

Requests are only ﬁlled for Nebraska residents, businesses or organiza ons.

Date: ________________________

PLEASE PRINT OR TYPE:

Name of Organiza on:__________________________________________________________________________________

Name of Person Reques ng Materials: _____________________________________________________________________

Mailing Address: _______________________________________________________________________________________

City: ______________________________________________, NE

Zip: ________________________________________

Telephone: _________________________________________ Email: _____________________________________________

ENGLISH MATERIALS

SPANISH MATERIALS

Please indicate quan ty requested on line provided (example: 10, 25, 40) unless limit is speciﬁed.

____ Nebraska Cessa on Resources Fact Sheet (NEW)

____ Nebraska Tobacco Quitline Magnet (Limit 25) (NEW)

____ Nebraska Tobacco Quitline Magnet (Limit 25)

____ Nebraska Tobacco Quitline Business Card* (Limit 25) (NEW)

____ Nebraska Tobacco Quitline Business Card (Limit 25)

____ Nebraska Tobacco Quitline What to Expect

Pa ent Brochure (NEW)

____ A er You Quit Smoking Card (NEW)

____ Nebraska Tobacco Quitline Healthcare Provider

____ Pens (Limit 25)

Fax Referral Program (NEW)

____ You Can Quit Smoking Primary Care Tear Sheet

Good Informa on for Smokers Brochure

Addi onal Spanish resources currently being update

_____

____ Helping Smokers Quit—A Guide for Providers

How will you use the materials?

____ 1-800-QUIT-NOW Plas c Cards

(Pa ent educa on, health fair/conference booth, etc.)

____ Tobacco Cessa on What You Need to Know

___________________________________________________

____ Smoking & Tobacco Pocket Slider (Limit 25)

Please allow 7-10 business days for delivery.

____ Qui ng for Life Handbook (Limit 25)

Ques ons? Email:

dhhs. n@nebraska.gov

____ Breath Mint Tins (Limit 25)

For more informa on:

____ Wrist Bands (Limit 25)

All materials while supplies last.

____ Stress Balls (Limit 25)

____ Pens (Limit 25)

* Design Shown Above

Updated 5.20.2016

Nebraska Tobacco Quitline - Order Form

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