Freedom from Smoking 2022

MetroHealth Online Freedom from Smoking^® 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.

** Participants will not be admitted after the second session

Today's date * +

What location would you like to attend class? *

First Name *

Last Name *

List other names you have gone by:

Email Address *

Street Address *

Birthdate: * +

City *

State *

Zip Code *

Phone Number *

Are you a MetroHealth patient? *

Yes

No

Which of these describes your ethnic group? *

What is your gender identity? *

Man

Woman

Non-binary

Prefer not to say