1. Contact Details for call

   We collect this information so that a Quitline advisor can contact you at your convenience. If an advisor is unable to reach you by phone, they may contact you via email to set up an alternative time.
2. Name Name is required Name accepts letters, whitespaces and dots only
3. Contact number Phone is required Phone accepts numbers only
4. Postcode Postcode is required Please specify a valid postcode
5. Email

6. Preferred call date

   We ask these questions so that the Quitline advisor can successfully call you back and offer appropriate advice.
7. Preferred call date Date format (dd/mm/yyyy) example: 27/04/2024

8. Preferred call time

9. Weekdays
   • 8am to 12pm
   • 12pm to 4pm
   • 4pm to 7pm
10. Saturdays
    • 9am to 12pm
    • 12pm to 4pm
11. Preferred language English Arabic Cantonese Mandarin Vietnamese Other (Telephone Interpreter Service) - please specify
    Language is required Please provide a valid language
12. 
    
    Would you like to talk to an Aboriginal counsellor?

    • No
    • Yes
13. Comments

14. * Required Fields

15. Please complete the captcha

For information on the Quitline privacy statement please click see the Quitline privacy statement