The Minnesota Quitline Network enables health professionals and community organizations to use a single form and fax number to refer the people they serve to tobacco quitline support. All Minnesota residents – whether covered by a health plan or not – have access to free support to quit.

Register for the Minnesota Quitline Network here, or use this form to update your site's information.

Is this a new registration, or are you updating your site's information?

1. New registration
2. Updating site information

What's your site ID?

Please provide the following information for your site.

Site name

Address

City

County

State

Zip

What type of site is this?

  Behavioral Health Dental Medical Public Health Other Please specify

Please provide a contact for this site. This person will serve as your primary contact and will be the point-person for inquiries about referrals made from your site.

Name

Phone

Fax

Email

How did you hear about the Minnesota Quitline Network?

1. Email or newsletter
2. Presentation
3. Website
4. Recommendation by a colleague
5. OtherPlease specify

The Minnesota Quitline Network issues quarterly updates with recent news, upcoming events and trainings, and new resources and tools to help you refer people to quitline support.

1. Keep me updated