Quad: Freedom from Smoking Registration (Feb 2025)

Freedom from Smoking: Nicotine/Tobacco Cessation Program

Tuesdays or Thursdays I Starting the week of February 10, 2025 I Virtual Sessions
Haga un click aquí para la registración en Español
Please choose your preferred date/time for your meetings:*
I am on a Quad Health Plan*

YesNoUnsure
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Mailing Address (We will mail you a packet for the class. If you feel more comfortable having this packet mailed to your site, feel free to put that address here)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your facilitator may send class summaries and communications regarding wellness topics covered which may elicit additional discussion via email amongst your class members. Participants may use the "Reply All" feature to start discussions and therefore your classmates may see your name/email. Being a part of these communications is on an “opt-in” basis. Please indicate below if you would like to be included in these communications.*

Yes, please include me in class communications that include the entire group.No, please do not include me in class communications with the group. I would prefer the facilitator sends me information individually.
What location do you work in? *
If you selected "other" for your location - what location do you work in?
What department do you work in?*
If you selected "other" for your department - what department do you work in?
How did you hear about this program? (Choose all that apply)*

EmailFlyersTV ScreenInsideQuad - QLife pageQuadMed ProviderCo-worker/Family memberOther
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Freedom from Smoking: Nicotine/Tobacco Cessation Program