An example of a stop-smoking agreement form

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An example a stop-smoking agreement form.

QUIT FOR GOOD RX
I agree to stop smoking on:
Date: _____/_____/______.
I understand that stopping smoking is the single best thing I can do for my health, and my
health professional has strongly encouraged me to quit.
Patient's Signature:________________________________
Health Professional's Signature:_____________________________
Today's Date:_____/______/_____

QUIT FOR GOOD RX
I agree to quit using tobacco on:
Date: _____/_____/______.
I understand that stopping using tobacco is one of the best things I can do for my health, and
my health professional has strongly encouraged me to quit.
Patient's Signature:________________________________
Health Professional's Signature:_____________________________
Today's Date:_____/______/_____

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