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Concierge Enrollment Form
Complete the form below to customize the type of messages you receive.
Name
*
First
Last
How would you like to receive program communications?
*
Text Message
Email
Mobile Phone Number
*
You’ll receive up to 1-4 messages/week from the number 43386. Message and Data rates may apply according to your carrier). You may opt out of receiving text messages at any time by texting “STOP” to 43386.
Email Address
*
You’ll receive up to 1-4 messages/week via email from
noreply@360smartercare.com
. You may unsubscribe at any time by clicking the Unsubscribe link in the email.
I am interested in:
*
Select up to 2
Pregnancy
Post-Partum Support
Cardiac Care
Mental Health Related Condition
Diabetes
Substance Abuse
Smoking Cessation
General Health and Wellness
Due Date
*
MM slash DD slash YYYY
Child's Birth Date
*
MM slash DD slash YYYY
Child's Name
*
Which of the following best describes your needs for substance abuse support?
*
I am currently abusing substances and am looking for general guidance/motivation to quit.
I am currently sober and seeking ongoing guidance/motivation to stay sober.
Which of the following best describes your smoking cessation interest?
*
I want to quit asap.
I eventually want to quit.
I have already quit.
Do you want to set your quit date now? We will help you prep for the big day:
*
Set quit date
No, not right now – remind me later
Set quit date:
*
MM slash DD slash YYYY
When was your quit day? We’ll send you supportive messages based on your quit date so you can continue a tobacco free lifestyle!
*
MM slash DD slash YYYY
I am interested in general health and wellness related to:
*
Please select one of the following options
Women's Health
Men's Health
My age range is:
*
18-29
30-45
46-60
60+
On a scale of 1-10, how would you rate your health mindfulness? (ex. Visiting doctor annually, staying on top of medications, making healthy choices to align with your care plan, calling your doctor when health concerns arise, etc.)
*
1 - I tend to struggle with staying on top of my health.
10 - I am great at staying on top of my health!
1
2
3
4
5
6
7
8
9
10
Do you smoke?
*
Yes
No
Are you interested in quitting?
*
Yes, I want to quit asap
I eventually want to quit, but not right now
I am not interested in quitting
Motivational support is key for keeping a positive mindset and getting on the path to a tobacco-free future. Would you like to receive a daily boost message?
*
Yes
No
Would you like your partner, caregiver or loved one to also receive educational information regarding your condition?
*
Yes
No
Caregiver's Name
*
First
Last
How would your caregiver like to receive program communications?
*
Text Message
Email
Caregiver's Mobile Phone Number
*
They’ll receive up to 1-4 messages/week from the number 43386. Message and Data rates may apply according to your carrier). You may opt out of receiving text messages at any time by texting “STOP” to 43386.
Caregiver's Email Address
*
They’ll receive up to 1-4 messages/week via email from
noreply@360smartercare.com
. You may unsubscribe at any time by clicking the Unsubscribe link in the email.
Terms and Conditions
*
I agree to receive periodic text messages related to the health-related topics selected above. I understand that text and email are not considered secure technology and that the messages I receive may indicate the nature of my health condition. However, beyond the general nature of my condition, I understand that this program does not send Protected Health Information (PHI) via text. I understand that the program uses text messages from my text plan and there are no additional charges.
I have read and agreed to the
terms and conditions
of this program.
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Current Date
MM slash DD slash YYYY
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Child Age Month
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