Medica - Enroll Now!

Member ID# *

Member ID:		Group Number:

Medica Membership Help

First name *

Last name *

What is your preferred phone number? *

What is your email? *

What is your zip code? *

What is your gender? *
MaleFemale

When were you born? *

(MM/DD/YYYY)

How can we best help you?
You want help - information about quitting
You want help - information about staying quit
You want general information or materials about the Medica QuitLogix Program

How did you hear about the Medica QuitLogix Tobacco Cessation Program? *

Where are you in the quit process?
No immediate interest in quitting
Want to quit in the next 30 days
About to quit in the next week
Quit in the last month
Quit in the last 6 months
Quit over 1+ year ago
NRT-Quitlogix

What tobacco product(s) are you currently using? *
Cigarettes
Chew Tobacco
Full Size Cigars
Small Cigars
Pipe
Hookah
Multiple

Uses:

Cigarettes/Day:
Chew Tobacco/Week:
Full Size Cigars/Week:
Small Cigars/Week:
Pipe/Week:
Hookah:

What is the highest level of education that you have completed? *
Less than grade 9
Grades 9 to 11, no diploma
GED
High school diploma
Some college or university
College or university degree
Graduate Degree
Do not wish to answer

Which of these groups would you say best describes you? *
Caucasian
Hispanic
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska native
Other
Multi-racial
Do not wish to answer

Are you Hispanic or Latino/Latina? *
YesNo

What is your marital status? *
Married
Divorced
Widowed
Single
Unknown
Do not wish to answer

Which program would you be interested in? *
Online QuitLine program only
Telephone and Online program

In order to complete the enrollment process, please select a date and time you will be available to receive a phone call from a coach.

Appointment

Date:

(MM/DD/YYYY)


Morning	Afternoon	Evening	Time:

** Appointments are in CST

Select a username, which will be used to login to the website.

Note: username must be at least 6 characters. You can use letters and numbers. The first character must be a letter. *

Choose a password, used to login to the site.

Note: password must be at least 6 characters. You can use letters, numbers and special characters. *

(Optional) Choose a screen name, which will be used in any chatrooms that you participate in.

Note: screen name can be any mix of letters or numbers, with no minimum number of characters.