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Get Use This Form To Refer Patients Who Are Ready To Quit Tobacco In The Next 30 Days To Quit Now

: Complete this section Provider name Contact Name Clinic/Hosp/Dept E-mail Address Phone ( City/State/Zip Fax ( ) ) - PATIENT: Complete this section Yes, I am ready to quit and ask that a quitline coach call me. I understand that Quit Now Kentucky will inform my Initial provider about my participation. Best times to call? morning afternoon Yes May we leave a message? evening No Are you hearing impaired and need assistance? Date of Birth? / / weeken.

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