SmokeBeGone Sign-Up

Complete the form below to book your 25-minute consult ($35) and choose your personal path to freedom.

Consult available in my Lloydminster office, live online, or by telephone. Everything you share stays in your confidential client file.

Your information

First name

Last name

Mobile phone

Age

City / Province

How did you hear about us?

Preferred format

How many years have you been a smoker?

How old were you when you started?

Why did you start smoking?

How many cigarettes in a package?

How many cigarettes do you smoke per day?

How much do you pay per package? ($)

Cost per cigarette (calculated automatically)

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On a scale of 1 to 10, how badly do you want to be a non-smoker?

Describe the reasons you want to be a non-smoker

Where do you smoke?

Describe an average smoking day

I have read and agree to the client consent form.