Medical University of South Carolina - MUSC Employee Wellness:Smoking Cessation Program Enrollment Form

Medical University of South Carolina - Smoking Cessation Program Enrollment Form

Smoking Cessation Program Enrollment is available to MUSC/ MUHA/ UMA/ CFC Employees and Students only.

Click on the following links for different Smoking Cessation Program details

Quit for Life
SC Quit Line
Pharmacy Counseling
Freedom from Smoking Clinic
Non Smoking Section

Email: musc-empwell@musc.edu

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Smoking Cessation Program Enrollment Form

Please fill out the information below. By submitting this enrollment form you agree to a program follow-up by phone or email to be conducted by Hollings Cancer Center, Cancer Prevention & Control for program evaluation purposes only.

First Name
Last Name
E-Mail Address
Phone#(format:xxx-xxx-xxxx)
Employment Category
.
You may be eligible for free medications to help you stop smoking.
Medication you are interested in
On average, how many cigarettes do you smoke per day?
Please select an exact number
Combining behavioral support with medications provides smokers with the best success for stopping smoking.
Please select which program(s)/dates you are interested in
(You may select more than one programs)
1.Quit for Life	Yes No
2.SC Quit Line	Yes No
3.Pharmacy Counseling	Yes No
5.Freedom from Smoking Clinic to be held on
6.Non Smoking Section class to be held on

People who use cigarettes to cope with stress may benefit from a stress management program. To see if you qualify, please answer the following question
A cigarette calms me down when I am stressed Totally disagreeDisagree Do not really agreeMore or less agree Fully agree
Are you enrolled in one of the State Health Plans? Yes No

If yes, what is your primary insurance in the state insurance plan?

CIGNAState Health Plan (Standard or Saving)BlueChoice/CompanionOther

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Medical University of South Carolina