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Order a quit kit

Quitting NOW is the single best thing you can do for your health. We can help!

DID YOU KNOW?

Of adolescents who have smoked at least 100 cigarettes in their lifetime, most of them report that they would like to quit. (source: American Lung Association)

 

GET ALL THE FACTS

Quit Kit Order Form For Someone Else

One simple step. That’s all it takes to order the FREE Maryland TRASH Quit Kit! To ensure proper delivery, please check to make sure ALL of the information you supply is accurate.

If you are ordering this kit for someone else please fill in the following information with them online or print out the PDF Form to fill out with them and send/fax it to us.

Quit Kit Order Form for someone else

  • Your contact information

  • Please be sure to enter your e-mail address correctly in the required form field. A confirmation e-mail will be sent to you which requires your reply to receive the kit.
  • Recipient Contact Information

  • We respect your privacy. The information collected on this form will only be used by Maryland TRASH to send you or a recipient a TRASH Quit Kit, as per your request. We won’t sell your info.

    By clicking submit below, you acknowledge our right to contact you and the recipient to follow-up, confirm your order, and mail the requested TRASH Quit kit to the address indicated by you.

  • Thank you for completing the Maryland TRASH Quit Kit Order Form!