Program Eligibility

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 Contact Us.

Are you filling this out during a community healthcare appointment?

Personal Information

First Name

Last Name

Date of Birth

Phone

Estimated Due Date

Please check the boxes below:

I attest that all 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.