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 Please enable JavaScript in your browser to complete this form.About You and Your PracticeName *FirstLastEmail *Hospital or Health System and Department *How many physicians/health care providers are at your practice(s)? *Your response will help us fulfill your order and ensure the long term availability of these free tobacco cessation resources.Please provide the name of a lead provider at your practice *FirstLastProvider Email *We may contact your practice's clinical lead for feedback on how our tools are used at point-of-care. What CQI(s) are you associated with? *ASPIRE - Anesthesiology Performance Improvement & Reporting ExchangeBMC2 - Michigan Cardiovascular Consortium - Percutaneous Coronary InterventionHBOM - Healthy Behaviors of MichiganHMS - Hospital Medicine Safety (HMS) ConsortiumI-MPACT - Integrated Michigan Patient-centered Alliance on Care TransitionsM-KIC - Michigan Kidney Improvement CollaborativeM-SHIELD - Michigan Social Health Interventions to Eliminate DisparitiesMAQI2 - Michigan Anticoagulation Quality Improvement InitiativeMARCQI - Michigan Arthroplasty Registry Collaborative for Quality ImprovementMBSC - Michigan Bariatric Surgery ConsortiumMCT2D - Michigan Collaborative for Type 2 DiabetesMEDIC - Michigan Emergency Department Improvement CollaborativeMiBAC - Michigan Back CollaborativeMOQC - Michigan Oncology Quality ConsortiumMROQC - Michigan Radiation Oncology Quality ConsortiumMSQC - Michigan Surgical Quality CollaborativeMSSIC - Michigan Spine Surgery Improvement CollaborativeMSTCVS - Michigan Society of Thoracic and Cardiovascular Surgeons Quality CollaborativeMTQIP - Michigan Trauma Quality Improvement ProjectMUSIC - Michigan Urological Surgery Improvement CollaborativeOBI- Obstetrics InitiativeDon't KnowNoneYour OrderHow 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 providerWould you like a set of posters, referral cards, and card holder for the Michigan Tobacco Quitline (1-800-QUIT-NOW)?YesNoWould you like to request any additional posters, co-created by HBOM partner members?Never Too Late: Patient Facing Poster #1 by MaryellenStop and Smell the Roses: Patient Facing Poster #2 by SandiEmojis: Patient Facing Poster #3 by MadelineKeep it Up: Patient Facing Poster #5 by AngelaCancer Survival: Patient Facing Poster #4Provider-Focused Posters, co-created by HBOM partner members:You Ask Because You Care: Provider Facing Poster #1Your words have impact: Provider Facing Poster #2Shipping Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIf shipping to a clinic or office, please include full details of office or mailbox number, building name, etc.Comments/questions?Submit
