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Get Utah Quit Now Form
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How to fill out the Utah Quit Now Form online
The Utah Quit Now Form is a crucial tool for individuals seeking support in quitting tobacco. This guide will provide you with clear, step-by-step instructions to complete this form online efficiently.
Follow the steps to fill out the form accurately and easily.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Provide your patient information. Begin by clearly printing your last name and first name, followed by your date of birth. Ensure you select your gender by marking either 'M' for male or 'F' for female.
- Next, fill in your address. Include the street address, city, state (UT), and zip code. Remember to provide multiple phone numbers where you can be reached, along with your email address.
- Indicate whether you are comfortable receiving text messages by marking 'Yes' or 'No'. Also, indicate your best times to be contacted: morning, afternoon, evening, or whether you are available on weekends.
- Confirm if you would like a message to be left by selecting 'Yes' or 'No'. Specify your preferred language from the provided options, and indicate if you require assistance due to hearing impairment.
- Express your readiness to quit tobacco by marking the checkbox and providing your initials. This step indicates your request for assistance from the Utah Tobacco Quit Line.
- Sign and date the form at the bottom to validate your response. This release is effective for one year.
- Proceed to enter provider information if applicable. Fill in the clinic, hospital, or department name, along with the contact person's name and address. Provide the email, city/state/zip, phone number, and fax number.
- Once all fields are completed, ensure to save any changes made to the form. You can then download, print, or share the form as needed.
Start your journey toward a healthier life by completing the Utah Quit Now Form online today.
Effective anti-smoking campaigns typically focus on education, personal stories, and community involvement. Campaigns that utilize the Utah Quit Now Form exemplify this by providing accessible resources and encouraging public engagement. These campaigns are successful because they resonate with individuals, fostering a collective effort to reduce smoking rates.
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