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Provider Login Page

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PO Box 277
Camp Hill, PA 17001
(p) 717-971-1134

This project is funded by a grant through
the PA Department of Health.

Contact

Quit Line Materials Order Form

Note: Incomplete forms will delay your order. Please fill in all requested information.

Name

Organization

Phone Number

Shipping Address

Address Line 2

City

State

Zip

Is this a residence?

No Yes

Vaping Posters

Vaping Poster: Save, Piggy Bank, Girl

Vaping Poster: Save, Wallet, Boy

Vaping Poster: Lungs Burning

Vaping Poster: What Would You Gain

Vaping Poster: Still Tobacco

Quitline Flyers

Rebecca

Roosevelt

Amanda

Felicita

Jessica

Quitline Square Cards

Rebecca

Rebecca-Spanish

Amanda

Roosevelt

Felicita

Jessica

Brian

LGBTQ

Ellie-Spanish

Brian’s Artery

Brian’s Artery-Spanish

Pregnancy Flyers

Pregnancy flyer, 11 x 17

Nicotine Replacement Therapy (NRT) Order Form

Note: Incomplete forms will delay your order. Please fill in all requested information.

Name

Organization

Phone Number

Shipping Address

Address Line 2

City

State

Zip

Is this a residence?

No Yes

Location of class

Date of classes/sessions

# of participants

NRT Description (order by the case, 1 case=12 boxes)

21 mg Patch (14 patches in each box)

14 mg Patch (14 patches in each box)

7 mg Patch (14 patches in each box

4 mg Lozenge (mini mint flavor- 81 pc per box, 4mg

2 mg Lozenge (mini mint flavor- 81 pc per box, 2mg

4 mg Gum (spearmint flavor- 100 pc per box)

4 mg Gum (white ice mint flavor- 100 pc per box

4 mg Gum (fruit flavor- 100 pc per box)

4 mg Gum (cinnamon rush flavor- 100 pc per box)

2 mg Gum (spearmint flavor- 100 pc per box)

2 mg Gum (white ice mint flavor- 100 pc per box

2 mg Gum (fruit flavor- 100 pc per box)

2 mg Gum (cinnamon flavor-100 pc per box)

Provider Login Page

Please login to access Provider Resources

PO Box 277
Camp Hill, PA 17001
(p) 717-971-1134

This project is funded by a grant through
the PA Department of Health.

Contact

Quit Line Materials Order Form

Vaping Posters

Quitline Flyers

Quitline Square Cards

LGBTQ

Pregnancy Flyers

Nicotine Replacement Therapy (NRT) Order Form

NRT Description (order by the case, 1 case=12 boxes)

YLAP Request Form

YLAP Thank You Cards & YLAP Toolkit

Provider Login Page

Please login to access Provider Resources

PO Box 277 Camp Hill, PA 17001(p) 717-971-1134

This project is funded by a grant through the PA Department of Health.

Contact

Quit Line Materials Order Form

Vaping Posters

Quitline Flyers

Quitline Square Cards

LGBTQ

Pregnancy Flyers

Nicotine Replacement Therapy (NRT) Order Form

NRT Description (order by the case, 1 case=12 boxes)

YLAP Request Form

YLAP Thank You Cards & YLAP Toolkit

PO Box 277
Camp Hill, PA 17001
(p) 717-971-1134

This project is funded by a grant through
the PA Department of Health.