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FreshStart Tobacco Cessation Interest Form
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First and Last Name
*
Phone Number (ex. xxx-xxx-xxxx)
*
Gender
*
Female
Male
LGTBQIA+
Prefer not to answer
Age Range
*
15-17
18-19
20-24
25-29
30-34
35-39
40-44
44+
Race
*
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than One Race
Prefer not to answer
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Source of Nicotine (Check all that apply)
*
Cigarettes
E-cigarettes or Vapes
Chew, spit, or snuff
Cigars, little cigars
Herbal cigarettes
Hookahs
Bidis
Age start first started using nicotine
*
10-12
13-17
18-27
28-39
40+
* indicates required fields.
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