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Complete the following form and you will receive a response within two business days.
Program participants must be pregnant when they begin the Baby & Me - Tobacco Free program.
Are you currently smoking cigarettes or e-cigarettes?
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.
Program participants have the option of enrolling a partner in the program. Does anyone else in your household smoke?
This field is not part of the form submission.
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