Patient Tobacco Cessation Program Enrollment Form

Streamline Your Tobacco Cessation Program Enrollment

Supporting patients through tobacco cessation requires careful assessment, personalized treatment planning, and ongoing coordination between healthcare providers and patients. This Patient Tobacco Cessation Program Enrollment Form helps healthcare clinics, hospitals, and wellness centers efficiently onboard new participants while gathering critical information about nicotine dependence, treatment preferences, and medical history.

Built for Healthcare Providers Who Care

Whether you're running a hospital-based smoking cessation program, a community health initiative, or a specialized behavioral health practice, this template captures everything you need in one streamlined form. It assesses nicotine dependence using evidence-based questions, evaluates contraindications for pharmacotherapy, and schedules initial counseling sessions—all while maintaining a professional, patient-friendly experience.

The form includes conditional logic that adapts based on patient responses, ensuring relevant follow-up questions appear only when needed. This reduces form abandonment and creates a more personalized enrollment experience that respects each patient's unique situation.

Paperform Makes Healthcare Forms Simple

With Paperform, you can customize this template to match your organization's branding, connect it to your patient management system, and automate follow-up workflows. The HIPAA-alternative compliant platform ensures patient data is handled securely, while integrations with tools like Google Calendar, Slack, and your CRM keep your team coordinated.

Need to send enrollment confirmations automatically? Want to trigger a welcome email series through your marketing platform? Paperform's native integrations and Stepper workflow automation make it easy to create sophisticated patient journeys without writing a single line of code.

From Enrollment to Engagement

This isn't just a registration form—it's the first step in a comprehensive care pathway. Use conditional success messages to provide immediate encouragement based on readiness to quit, schedule initial counseling appointments directly within the form, and automatically route high-dependency patients to appropriate treatment intensity levels.

For healthcare administrators and program coordinators, Paperform's AI Insights can help you identify trends across enrollments, understand common barriers to cessation, and optimize your program based on real patient data. Whether you're managing 20 patients or 2,000, you'll have the visibility you need to deliver better outcomes.

Start with this template and customize it to reflect your program's specific protocols, pharmacotherapy options, and counseling approaches. With Paperform, you get enterprise-grade security and SMB-friendly simplicity—so you can focus on what matters most: helping patients quit tobacco for good.