Register - MyQuit Smoking Cessation

Name*

First Last

Phone*

Postal Code*

MyQuit services are available in the following Eastern Ontario communities: City of Ottawa, Renfrew County and District, Lanark County, Leeds & Grenville, Prescott-Russell, Stormont, Dundas & Glengarry, and the City of Cornwall.

We see from your postal code that you are from another region. Please visit the Help By Province page to find out how to connect with smoking cessation services near you.

Email

Language of Preference: (Our operators are able to deliver service directly in English, French and in other languages through a translator.)*

When is the best time to call you?*

Morning
Afternoon
Evening
Anytime

Can we leave a message and identify that we are calling from MyQuit?*

Yes
No

How did you hear about MyQuit?*

Consent*

I give permission for this registration form to be submitted to MyQuit so that I can be contacted by a MyQuit partner regarding my attempt to quit smoking. I understand that my information will be kept secure and confidential and will only be used for the purpose of administering and evaluating the MyQuit program.

Ready to get started?