Aanmeldformulier Stoppen Met Roken - Nationale Apotheek (ENG)

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Sign up to quit smoking with Nationale Apotheek and get coaching and quit smoking products fully covered once a year. You don’t pay any extra costs.
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Name*

First NameLast Name
Email*
Phone Number*

Your coaching preferences
Please fill in your preferences below, and we will find the coaching that best suits your needs.
1. What language would you like for the quit smoking coaching?*
Engels
Turks
Arabisch
Duits
Spaans
Fries
Farsi
2. How would you like to receive coaching?*

At a local location (with a coach in your region)Online or by phone
3. Do you want group coaching or individual coaching?*

Group (with others)Individual (one-on-one)
4. You have selected coaching at a local location. Which location do you prefer? Please select a province in the Netherlands from the list below:*
5. Please select a place in Drenthe:*
5. Please select a place in Flevoland:*
5. Please select a place in Friesland:*
5. Please select a place in Gelderland: *
5. Please select a place in Groningen:*
5. Please select a place in Limburg:*
5. Please select a place in North Brabant:*
5. Please select a place in North Holland:*
5. Please select a place in Overijssel:*
5. Please select a place in Utrecht:*
5. Please select a place in Zeeland:*
5. Please select a place in South Holland:*
Note: is your preferred place not on the list?
Then choose another place, or select Online or by phone in question 2.
Op locatie - Individueel
Online - Individueel
Doorsturen naar: Medipro

Medipro
Doorsturen naar: WeQuit

WeQuit
Doorsturen naar: Rookvrij & Fitter

Rookvrij & Fitter
Click ‘Submit’ to finish your registration. Within 2 working days, our partner Medipro will contact you for a short, non-binding introduction call. Medipro is a trusted coaching agency we have worked with successfully for many years.
Click ‘Submit’ to finish your registration. You will receive an email from our partner WeQuit with a link to register online. Having trouble registering online? WeQuit will contact you within 2 working days for a short, non-binding introduction call. WeQuit is a trusted coaching agency we have worked with successfully for many years.
Click ‘Submit’ to finish your registration. Within 2 working days, our partner Rookvrij & Fitter will contact you for a short, non-binding introduction call. Rookvrij & Fitter is a trusted coaching agency we have worked with successfully for many years.
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