Request a Quit Guide
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Date of Birth
Please enter your date of birth
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I'm submitting this on behalf of:
My patient or client
My family member
Name of Healthcare Provider or Referring Facility:
Southeastern Behavioral Health
Faulk County Sheriff's Office
Name of referring staff:
Name of referring clinic:
Would you like to receive the additional 2-week NRT medication (patches, gum or lozenges)?
I verify that I am a South Dakota resident
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