Tobacco Cessation Services - Interest Form

City of Cleveland - Department of Public Health

* Required Fields(s)

First Name: *

Last Name: *

Phone Number - Landline:

Phone Number - Cellphone:

E-Mail Address:

Home Zip Code:

Are You 18+ Years of Age?: *

Currently Employed?:

What is the best way to reach you?:

What is the best time to reach you?:

Do you plan to quit within the next 6 months?:

Will you set a quit date within the next 30 days?: