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Pharmacy to Community Tobacco Cessation Project
Interest Form
*
1.
Name of your Organization:
(Required.)
*
2.
Contact Information:
(Required.)
Name
Address
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
*
3.
Do you currently provide smoking cessation services?
(Required.)
Yes
No
*
4.
How would you like to participate in the Lucas County Tobacco Community Cessation Initiative?
(Required.)
Cessation Provider
Referral Partner
Both
I would like more information
5.
Any questions or comments?
Current Progress,
0 of 5 answered
