AGENCY ENROLLMENT
1-866-QUIT-YES

1-866-784-8937

Tobacco Treatment Enrollment Form

PARTICIPANT INFORMATION

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PARTICIPANT CONSENT

I authorize the release of the information on this enrollment form to Illinois Tobacco Quitline (ITQL) for purposes of my participation in the tobacco cessation program and also authorize ITQL and it representatives to contact me at the phone number(s) listed above. I give the ITQL permission to discuss my use of service.

REFERRAL AGENCY
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