Complete only if you answered “Yes” to any of the health conditions on the Waiver Letter in this packet. If you have told to us either during the enrollment call or on the attached waiver letter that you have one or more of the health concerns listed, you will need to complete this section. You may complete this form yourself and do not need to ask your doctor to do it. We will be contacting your doctor for you. You may tell your doctor that we will be contacting her/him by fax and to respond in a timely manner.
Type your initials after each of this statements to agree:
Thank you for completing this form. A WV Tobacco Quitline Coach will be in contact with you soon.