The Illinois Tobacco Quitline 1-866-QUIT-YES

REQUEST A CALL FROM THE QUITLINE

To request a call please complete the form below. Required fields are in BOLD.

First Name     Last Name
Address   
City    State: ZIP:
Phone   
Email Address   
Gender    Female    Male
Ethnicity   
Age   
   Would you like to receive a call from the Quitline?  Yes  No
If yes, when should we call?:    (CST)
   Would you like to receive an email response to your tobacco quit line questions?  Yes  No
   Would you like to receive printed materials related to your question?   Yes    No
Is there a specific problem you would like to discuss?
If so, describe below:
How did you hear about the Tobacco Quitline?

 

CLICK HERE TO REQUEST INFORMATION FROM THE QUITLINE

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