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When you enroll in My Life, My Quit™, you will have access to free and confidential text, phone and online support. Please complete the form to get started.

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What state do you currently live in?

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Disclaimer : We do not provide medical care. Talk to your doctor about your plan to quit tobacco and use of nicotine replacement or other quit smoking medicine if you have any questions or problems.
Read Disclaimer? Yes

Do you have a history of any of the following? Check all that apply.

None

Asthma

Emphysema, Chronic Bronchitis, or COPD

History of seizures

Diabetes

Cancer

Heart disease, irregular heart rate, or angina

Heart attack within the last 12 months

Stroke within the last 12 months

High blood pressure

High blood pressure is controlled with medication

Skin condition (eczema, psoriasis, etc.) or allergies to adhesives

Use dentures or have sensitive gums

Currently pregnant Yes No

Due Date?

Currently breastfeeding Yes No

Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?

If your state is not listed, please call 1-800-QUIT-NOW (784-8669) or visit teen.smokefree.gov to get help.

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