Enroll Now

Tell Us About Yourself

Medical Conditions

Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.

All fields required All questions are required At least one selection is required
When you enroll in the Colorado QuitLine, you will have access to free personalized phone coaching, free patches or gum, an interactive website and text messaging support.
When you enroll in My Life My Quit, you will have access to free and confidential text, phone and online support.  Please complete the form to get started.
* Required

Do you have a history of any of the following? Check all that apply.
Yes No
Yes No
Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?