Patient Name:
Date of Birth: (mm/dd/yyyy)
Primary Phone:
Tobacco Types (check all that apply) Cigarettes Smokeless Tobacco Cigar Pipe
The patient is ready to quit tobacco in the next 30 days and requests the Quitline contact him or her with quit plan help.
The patient DOES NOT give permission to the Quitline to leave a message when contacting him or her.
The patient agrees and accepts the terms of this form submission.
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Best time to call 6 am - 9 am 9 am - 12 pm 12 pm - 3 pm 3 pm - 6 pm 6 pm - 9 pm