Smoking Cessation Registration
Whether this is your first attempt at quitting smoking or your 10th, the Pride Center is here to help you succeed and quit for good! After completing this form, a tobacco treatment specialist will reach out to you to schedule an intake assessment.
Name
First Name
Last Name
Pronouns
(i.e.: she/her, he/him, they/them)
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
At what age did you start using tobacco on a regular basis?
In the past six months, what is the average number of cigarettes (or other tobacco products) you have used per day?
Are you currently using an electronic nicotine delivery system (e-cigarette, vape, etc.)?
Yes
No
How many times have you made a serious attempt to quit smoking or using tobacco products?
0
1
2
3
More than 3
If you have tried to quit in the past, what methods have you used? (check all that apply)
Nicotine patch
Nicotine gum
Nicotine inhaler
Nicotine nasal spray
Nicotine lozenge
Zyban/Wellbutrin/bupropion
Chantix / varenicline
Cold turkey
If you attempted to quit in the past before and found success, how long were you able to stay nicotine-free?
Submit
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