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Tell Us About Yourself

Medical Conditions

Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.

Tell Us More About Yourself

All fields required All questions are required At least one selection is required
When you enroll in My Life, My Quit™, you will have access to free and confidential text, phone and online support.  Please complete the form to get started.
 
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Yes
Do you have a history of any of the following? Check all that apply.
Yes No
Yes No
Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?








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