• Confidential New Patient Intake Form - Quit Smoking

  • Smoking History:

  • Important questions:

  • Quitting History:

  • Your feelings about quitting smoking:

  • Please answer the following questions to help us understand you better:

  • Please type your initials in the above box agreeing that you have understood the above statement:

  • Clear
  •  -  - Pick a Date  :
  • I have been informed that I need to provide 24 hour notice should I want to cancel or reschedule an appointment. Cancellation fees may apply if I don't give enough notice.

  • Clear
  • Should be Empty: