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Tell Us About Yourself

Medical Conditions

Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.

Tell Us More About Yourself

All fields required All questions are required At least one selection is required
To enroll in the program, we need to get some information from you. The next several pages will ask you questions about you and your tobacco history. Once you have completed the questions, we will begin this journey together!
 




































































Yes
Do you have a history of any of the following? Check all that apply.
Yes
Yes



























Thank you

Congratulations on enrolling in the quitline and committing to building a healthier life for you and those you love.  In joining the program, you are taking your first steps toward becoming tobacco free. You will receive an email with your enrollment details within one business day.  To continue reaching for your goals with your quit journey, click here.