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


Created by:

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
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
2.SC Quit Line
3.Pharmacy Counseling
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
Are you enrolled in one of the State Health Plans?
If yes, what is your primary insurance in the state insurance plan?
Cannot open database "Health1st" requested by the login. The login failed. Login failed for user 'Health1st'.
Medical University of South Carolina