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Please complete all fields

Email Address*


Age when you started smoking? How many Years?

Have you tried to stop before? What were the results?

Whats the longest period you have gone without smoking?

What caused you start again?

On a scale of 1-10 what is your commitment to becoming smoke free?

What has been the greatest barrier to stopping in the past?

Is there a reason that you have chosen this time to stop?

Are you ready and willing to live your life smoke free?

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