Are you pregnant and 36 weeks gestation or less?
Are you a current tobacco user, quit since becoming pregnant, or quit within 3 months of becoming pregnant?
If either answer is 'No', you are not eligible to enroll in the BABY & ME-Tobacco Free Program.
For more information please
Are you filling this out during a community healthcare appointment?
Date of Birth
Estimated Due Date
Please check the boxes below:
I attest that the information provided about me in this referral (I.e.-eligibility and personal information) is correct, accurate, and complete.
I agree to having my personal information shared with the National BABY & ME-Tobacco Free Program.
I opt-in to receive text messages, phone calls, and emails, including voicemails and/or SMS messages, as it relates to enrolling and being a participant in the BABY & ME-Tobacco Free Program.
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