Please complete the form below as best you can so I can customize your success!Name *Email Address *PhoneHow many cigarettes do you smoke in a day?How long have you been smoking?When do you smoke?On wakingAt breakfastAfter mealsDrivingWith coffeeOn the phoneAt workSociallyIn bedOther times?What's the most important reason(s) for you to become a non-smoker?Controlled by cigarettesMoney/Expense of smokingChildrenSmell of smokingCurrent health problemsHealthy but concerned about your future healthCoughs and coldsBreathingDeath and dyingPressure from other peopleInconvenience of smokingAnti-social pressuresOther reason(s)What other methods have you tried (if any) to stop smoking?Are you currently seeing a doctor other health professional about your smoking? *YesNoWhat other information is relevant to your smoking I should know about?How do you want me to contact you? *By phoneBy text messageBy emailBest time(s) to connect with you? *Submit your information!