Enroll

Complete this brief Enroll Now form.

This is a secure and HIPAA compliant website.


What is your preferred language?

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What is your gender?

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Do you have health insurance?

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What insurance do you have?

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What is your zip code?

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First name

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Last name

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What is your preferred phone number?

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What is your email?

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When were you born?

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How can we best help you?

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How did you hear about Quit Now Kentucky?

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Where are you in the Quit Process?

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What tobacco product(s) are you currently using?

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Cigarettes

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SLT, chew tobacco, snuff, or dip

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Cigars, cigarillos, or small cigars

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Pipes

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Have you used an e-cigarette or other electronic “vaping” product in the past 30 days?

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How many days did you use an e-cigarette or electronic “vaping” product in the last 30 days?

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Other tobacco products

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How many cigarettes per day?

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How much SLT, chew tobacco, snuff, or dip per week?

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How many cigars per week?

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How many pipes per week?

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How much other tobacco per week?

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People use e-cigarette/e-vaping products for a variety of reasons, are you currently using e-cigarettes/e-vaping products to quit smoking?

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Do you use an e-cigarettes/e-vaping product that contains nicotine?

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Do you intend to completely quit using e-cigarettes/e-vaping products within the next 30 days?

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

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What is your race?

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White

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Black or African American

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Asian

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Native Hawaiian or Pacific Islander

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American Indian or Native Alaska:

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Please specify name of enrolled or principal tribe:

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Some other race

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Which specific Asian ethnicity or race do you identify with more?

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Which specific ethnicity or race do you identify with more?

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Are you of Hispanic or Latino/Latina origin?

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What specific heritage?

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What is your marital status?

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

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Indicate all of the following which apply to you: Bisexual, Gay or [for a woman] lesbian, Queer, Transgender or gender variant and assigned male at birth, Transgender or gender variant and assigned female at birth.

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Bisexual:

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Gay or [for a woman] lesbian:

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Queer:

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Transgender or gender variant and assigned male at birth:

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Transgender or gender variant and assigned female at birth:

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Please tell us which program you are interested in.

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Please enter the best times to call you.

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Please enter the best days to reach you.

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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?

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Please select a username, which will be used to log into the website.

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