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Ready to cut back?

Ready to cut back?

We're a team of clinical professionals. Ready to pay you to cut back. We take your privacy very seriously - all info you provide is safe & secure!

1
Name
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
What is your address & what state do you live in?This will help if we have to ship anything to you!
5
What type of phone do you have?* This field is required.
Android/Samsung
iPhone
6
How many cigarettes do you smoke per day?
5 or less
Half a pack
One Pack
One to Two Packs
Two or more
7
How motivated are you to quit smoking in the next 30 days?1 being the least motivated, 10 being the most motivated
1
2
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5
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9
10
Motivation
Motivation
1
2
3
4
5
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8
9
10
8
How long after you wake up do you have your first cigarette?
Less than 30 minutes after you wake up
More than 30 minutes after you wake up
I'm not sure
9
How confident are you that you could be successful at quitting smoking?1 being the least confident, 10 being the most confident
1
2
3
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5
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8
9
10
Confidence
Confidence
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What is your annual income, roughly?
Less than $20K
$20K-$40K
$40K-$60K
$60K-$80K
$80-$100K
More than $100K
11
Do you have any existing medical conditions?
High Blood Pressure
Chronic obstructive pulmonary disease (COPD)
Chronic Heart Failure
Diabetes
I've had a heart attack or stroke in the last 5 years
I'm not sure
12
What health insurance do you have?This helps us find a way to help you faster!
Medicare
Medicaid
Blue Cross Blue Shield
Blue Care Network
Blue Cross Complete
United Health
Cigna
Aetna
Humana
Molina Healthcare
Priority Health
Meridian Health
I'm not sure
13
What is your date of birth?
Date
Year
Month
Day
14
Do you have an image of your health insurance card?This helps us reach you SO much faster!
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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15
Anything else you'd like to share with us?Why are you visiting? Are you ready to quit? Do you have a loved one you'd like to help? Leave a note below :)
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