Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Baby & Me - Tobacco Free Application

  1. Baby & Me - Tobacco Free Program Application
    Complete the following form and you will receive a response within two business days.
  2. BMTF
  3. Program participants must be pregnant when they begin the Baby & Me - Tobacco Free program.
  4. If you are not currently smoking, when was the last time you smoked a cigarette or e-cigarette (even a puff)? If you are currently smoking, put today's date.
  5. Note: Please be aware this form is not a secure method of communication. Please do not include information in this form you would like to remain confidential.
  6. Tri-County Health Department logo
  7. Leave This Blank:

  8. This field is not part of the form submission.