Nicotine Replacement Therapy Reimbursement Program Intake Form

Section 1

First Name*

Middle Initial

Last Name*

Birth Date

Are you a Citizen of the Métis Nation–Saskatchewan?*

Yes

Citizenship Number*

Sorry, you have to be a citizen or an immediate family member of a citizen from the Métis Nation–Saskatchewan to proceed.
Apply for MN-S Citizenship

Street*

City*

Postal Code*

Phone

Email Address*

Emergency Contact Information Name

Emergency Contact Phone Number

Section 2

For what type(s) of NRT medicine are you seeking reimbursement?

Type(s) of NRT medicine for reimbursement

Please check all that apply

Transdermal Nicotine Patch

Nicotine Gum

Nicotine Lozenges

Nicotine Inhaler

Champix (or generic equivalent Apo-Verenicline)

Zyban SR (or generic equivalent Apo-Bupropion)

Please upload doctor’s note/prescription*

Max. file size: 30 MB.

Please upload doctor’s note/prescription*

Max. file size: 30 MB.

Are you using counselling/therapy to help you quit commercial tobacco?

If yes, you can get reimbursed for your appointments.

Yes

Receipts from your counselling appointments

Drop files here or

Max. file size: 30 MB.

Section 3

We’d love to hear more about your quitting journey.

Some options available to you are:

Call a helpline
Talk Tobacco @ 1-833-998-TALK (8255) or online https://smokershelpline.ca/talktobacco/home. A free a confidential program offering culturally appropriate support and information about quitting smoking, vaping, and commercial tobacco use for First Nations, Inui, Métis and urban Indigenous communities.
Smoker’s Helpline @ 1-877-513-5333 or online https://www.smokershelpline.ca
Counselling
Nicotine replacement therapy
Peer support

Since using this program, have you reduced your commercial tobacco use (smoking, vaping etc.)?

Yes

Describe tobacco-use reduction

How would you describe your tobacco-use reduction (e.g. number of smokes/vapes per day, changing when you smoke/vape etc.)

Section 4

Reimbursement options.

Attach EFT or void cheque for reimbursement*

Drop files here or

Max. file size: 30 MB.

In your words, please describe your plan for quitting/reducing your tobacco use*

Medical

Nicotine Replacement Therapy Reimbursement Program Intake Form

Section 1

Section 2

Section 3

Section 4