Tobacco Cessation Referral Form 
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A partnership between Hood River County Prevention Department and North Central Public Health District for Wasco, Sherman and Hood River counties. 
First Name *
Last Name
Phone Number *
Email  *
Best way to reach you? *
Required
OK to leave a message? *
 Do you need spanish language interpretation?  *
Which County do you live in?  *
This program is intended for residents of Wasco, Sherman & Hood River counties. 
Required
How did you hear about this service
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Are you an agency/doctor's office referring someone else for this service?  *
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