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Quit Form

THIS INFORMATION WILL BE CONFIDENTIAL. THIS INFORMATION IS ONLY VIEWED BY JIMMY MITCHELL, PROGRAM COORDINATOR OF THE TOBACCO PROGRAM.  ALL INFORMATION WILL BE LOCKED UP AND VIEWED ONLY BY THE PROGRAM COORDINATOR.

 

 

First Name:
Last Name:
Address:
Email:
How may we contact you:
Your voice videophone or IP number:
Your choice of tobacco:
How many a day:
Reason you want to quit:
Number of times you have tried to quit:
What have you used to try to quit:
Other information you would like to share:
* required        
  
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