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Details About You
Date of Birth DD/MM/YYYY
Are you of Aboriginal or Torres Strait Islander origin? Please select...
Yes
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Are you currently smoking or have you recently quit smoking (more than 24 hours ago)? Please select...
Currently Smoking
Recently Quit Smoking
Would you be prepared to be contacted in the future for research or evaluation purposes? Please select...
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How did you hear about Quitline? Please select...
Advertising
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Cigarette Pack
Resource/Course
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Other (Please Specify)
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Are you the holder of a Centrelink Health Care Card? Please select...
Yes
No