Request a Tobacco Cessation Box

Quit Smoking Resource Guide Tear Off Pad (50 Sheets)

Quit Smoking Medication Card

Tap for Support NFC Badges

Value Based Reimbursement (VBR) Toolkit

Name *

First

Last

Email *

Hospital or Health System and Department *

What CQI(s) are you associated with? *

How many Quit Smoking Resource Guide Tear Off Pads (50 Sheets per pad)?

RECOMMENDED: Order 1 pad for every 50 patients who need tobacco counseling in a six month period. So if your practice has about 200 TC patients in a 6 months period, order 4 pads, 2000 TC patients in that time, order 40 pads.

How many Medication Quick Options Cards?

How many Value Based Reimbursement (VBR) Toolkits?

RECOMMENDED: Order 1 per practice site. This request if for a physical copy of the toolkit. A digital version is available to you on our website.

How many Tap for Support NFC badges?

RECOMMENDED: Order 1 badge per provider

Would you like a set of posters, referral cards, and card holder for the Michigan Tobacco Quitline (1-800-QUIT-NOW)?

Would you like to request any additional posters?

Shipping Address *

Address Line 1

Address Line 2

City

State

Zip Code

If shipping to a clinic or office, please include full details of office or mailbox number, building name, etc.

Comments/questions?