Please provide the following information to help your Mayo Clinic care team assess your medical needs. When you have filled out and submitted this form you will be contacted by the Nicotine Dependence Center to review your registration request and explain additional program details.
Please identify the program in which you are requesting enrollment.
Note: Programs may be rescheduled due to participation requirements. If this occurs you will be notified and provided the opportunity to reschedule your participation.
Important: After submission, please do not leave this form until you see the confirmation message.
Your Mayo Clinic number is a 7, 8 or 9-digit number we assign to you as a new patient prior to your first visit. You can find it near the top of a range of documents, including pre-visit questionnaires, clinical notes, care summaries, and correspondence.
If you do have Mayo paperwork handy, it's often quickest simply to look for it there. Scroll down to see some examples of how the number shows up: