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Referral Form - New

Congratulations on taking an important step towards a smoke-free you!

Please enter your patient's information below
Provider Information *This question is required.
1. Which best describes you? *This question is required.
This question requires a valid date format of MM/DD/YYYY.
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I am the child(ren)'s
2. Please tell us about yourself (Fill out completely)
This question requires a valid date format of MM/DD/YYYY.
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Is it a cell phone or landline?
Is it a cell phone or landline?
This question requires a valid email address.
What is your race? (Check only one)
What is your preferred language
What is your insurance type?
3. Tell us about your smoking over the past week
A. How many cigarettes have you smoked PER DAY on average ? (Note: 1 pack = 20 cigarettes)
B. Did you use non-cigarette nicotine products (vape/e-cig, chew, cigars, etc) over the past week?
4. Pregnant/New Moms ONLY: Tell us about your smoking BEFORE you knew were pregnant
A. How many cigarettes did you smoke PER DAY BEFORE on average ?
B. Did you use non-cigarette nicotine products (vape/e-cig, chew, cigars, etc)?