Pharmacy to Community Tobacco Cessation Project

Interest Form

Question Title

* 1. Name of your Organization:

Question Title

* 2. Contact Information:

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 3. Do you currently provide smoking cessation services?

Yes

No

Question Title

* 4. How would you like to participate in the Lucas County Tobacco Community Cessation Initiative?

Cessation Provider

Referral Partner

Both

I would like more information

Question Title

* 5. Any questions or comments?