MetroHealth Nicotine Dependence Prevention and Treatment Program

Any information given on this form is voluntary and will remain confidential. It will help us to determine your individual  needs to quit so that the correct treatment is available for you.
 
Please ask the program leader if you have any questions about this form at 216-778-3031 or email mhquitsmoking@metrohealth.org.
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Best time to contact you *
Are you a MetroHealth patient? *
Which of these describes your ethnic group? *
 
What is your gender identity? *
How is your health? *
What type(s) of nicotine products do you use? Check all that apply. *
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