Patient Enrollment Forms

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.





Universal QuitWorks Enrollment Form (English)

Universal QuitWorks Enrollment Form (Spanish)






Customized Enrollment Forms
Many 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.

Hospitals
Anna Jaques Hospital
Brigham & Women's Hospital
Caritas Christi Health Care
Franklin Medical Center
Harrington Hospital
Holyoke Medical Center
Lawrence General Hospital
Lawrence General Hospital - Spanish
Lowell General Hospital
Marlborough Hospital
Marlborough Hospital - Spanish
Massachusetts General Hospital
MetroWest Medical Center
Noble Hospital
North Shore Medical Center
Southcoast Hospitals Group
Tufts Medical Center
UMass Health Alliance
UMass Memorial Medical Center
UMass Memorial Medical Center - Spanish
Wing Memorial

Health Centers
Chicopee Health Center
The Community Health Center of Franklin County
The Community Health Center of Franklin County - Spanish
Dimock Center
East Boston Neighborhood Health Center
East Boston Neighborhood Health Center - Spanish
Family Health Center of Worcester
Great Brook Valley Health Center
Greater Lawrence Family Health Center
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
Manet Community Health Center
Mattapan Community Health Center
MGH-Revere Healthcare Center
RoxComp Community Health Center

Public Health Programs
Boston Public Health Commission
Boston Public Health Commission - Spanish
Child and Family Practitioners
EIPP
Home Health VNA
Massachusetts Rehabilitation Commission (MRC)
Partners HealthCare System
Women's Health Network/Men's Health Partnership