Quitline Enrollment BPH

Thank you for enrolling in the West Virginia Tobacco Quitline. If you DO NOT have WV Medicaid, you are required to complete this additional form to receive services:
Name

First NameLast Name
Address for Shipping*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand I must be at least 18 years of age to receive this service. Please input birthdate:*

MonthDayYear
Date
Please attach a photocopy of your West Virginia driver’s license or other document establishing proof of age and West Virginia Residency.

Cancelof
Indicate the amount of cigarettes smoked per day*
Indicate pouches or tins of tobacco used per week*
Indicate number of cigars/pipes smoked per week*
I am requesting (one only)*

PatchesGumLozenges
The West Virginia Tobacco Quitline wants to be sure that you can use nicotine replacement products safely. Listed below are concerns that we and your physician need to know if you want to use nicotine replacement products. Please check any and all of the conditions that apply to you.*

I am pregnantI have had a recent heart attack (within 2 weeks)I have an irregular heartbeatNone of the above apply to me
Complete only if you answered “Yes” to any of the health conditions on the Waiver Letter in this packet. If you have told to us either during the enrollment call or on the attached waiver letter that you have one or more of the health concerns listed, you will need to complete this section. You may complete this form yourself and do not need to ask your doctor to do it. We will be contacting your doctor for you. You may tell your doctor that we will be contacting her/him by fax and to respond in a timely manner.
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.
Doctor's Fax Number
Please enter a valid phone number.
Type your initials after each of this statements to agree:
1. I agree to stop using nicotine replacement products and see my doctor if I become pregnant while using quit tobacco products.*
2. I agree to stop using nicotine replacement products and see my physician if side effects that do not go away after 4 days.*
3. I agree to stop using nicotine replacement products if I develop an irregular heartbeat.*
In consideration of the Bureau for Public Health and First Choice agreement to enroll me in the West Virginia Tobacco Quitline and to provide tobacco quitting services to me, I waive all claims for damage or loss to myself and property that may be caused by any act, or failure to act, of the Bureau for Public Health or First Choice, its officers, agents, successors, assignees, or employees. I agree to assume all risk of harm related to or resulting from my participation in the smoking cessation program, and I waive any and all specific notice of the existence of any such conditions or possible harm. Please sign your name to acknowledge this:*

Clear
Thank you for completing this form. A WV Tobacco Quitline Coach will be in contact with you soon.
Should be Empty:

Thank you for enrolling in the West Virginia Tobacco Quitline. If you DO NOT have WV Medicaid, you are required to complete this additional form to receive services: