The QuitSmokingCoach

Please print this form, complete it and mail it to the address below

Mail to:

Blair Price
27 Hyde Park Drive
Richmond Hill, Ontario
Canada  L4B 1V2

Make all checks and Money Orders Payable to:

Blair Price


Your Name: ____________________________

Email Address: __________________________

Your Quit Date: __________________

Please fill out this Information Form to tell me a bit about your smoking habits, how long you have smoked, what method you are using to help you to quit, and your reasons for quitting smoking. It will also include your quit date so that my program can begin on this date. This information will assist me to personalize your support program.