Online Live Richmond/Henrico Tobacco Cessation Classes
Please complete this registration form for the 5-week Online Tobacco Cessation Classes from 12pm1pm on Thursdays 12/2/21, 12/09/21, 12/16/21, 12/23/21 and 12/30/21.
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Contact phone number *
Best Way to Contact you *
What Tobacco product(s) do you currently use? (Check all that apply) *
Required
Do you use menthol flavored tobacco products? *
How many years have you used tobacco products *
Have you tried to quit? If yes, tell us more: what did you try? What  worked and didn't work? *
Please read the following and check the box acknowledging your understanding. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Commonwealth of Virginia. Report Abuse