Complete this brief Enroll Now form.

This is a secure and HIPAA compliant website.

What is your preferred language:

What is your gender?*

Do you have health insurance?*

What is your zip code?*

First name*

Last name*

What is your preferred phone number?*


What is your email?*

When were you born?*


How can we best help you?*

How did you hear about Quit Now Kentucky?*

Where are you in the Quit Process? *

What tobacco product(s) are you currently using?*

What is the highest level of education that you have completed? *

Are you Hispanic or Latino/Latina?*

Which of these groups would you say best describes you?*

What is your marital status?*

Do you consider yourself to be gay, lesbian, bisexual, and/or transgender? *

Which program would you be interested in?*

After you participate in this program, we will contact you by phone to ask you a few questions about our services. We use this information to improve our program. All information is kept strictly confidential and you can refuse to answer any of the questions the interviewer may ask. Is this ok?

Select a username, which will be used to login to the website. *
Note: username must be at least 6 characters. You can use letters and numbers. The first character must be a letter.

*Indicates required information