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Baby & Me - Tobacco Free Application

  1. Baby & Me - Tobacco Free Program Application

    Complete the following form and you will receive a response within two business days.

  2. BMTF

  3. Program participants must be pregnant when they begin the Baby & Me - Tobacco Free program.

  4. If you are not currently smoking, when was the last time you smoked a cigarette or e-cigarette (even a puff)? If you are currently smoking, put today's date.

  5. Note: Please be aware this form is not a secure method of communication. Please do not include information in this form you would like to remain confidential.

  6. Tri-County Health Department logo

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  8. This field is not part of the form submission.