Nicotine Dependence Center Residential Treatment Program

Registration Request

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.

Patient Information

Mayo Clinic Number:

(optional)

Title:

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First Name:

Middle Name:

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Last Name:

Email:

Gender:

Marital Status:

(optional)

Maiden Name:

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Spouse Name:

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Previous Married Name:

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Former Spouse Name:

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Birth Date:

MonthDayYear

Country:

Address:

City:

State/Province:

Postal Code:

Home Phone:

Cell Phone:

(optional)

Work Phone:

(optional)

May we contact you at work?

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Name of Nearest Living Relative or Friend:

(optional)

Relationship:

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Home Address of Relative or Friend - Street

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City, State, ZIP Code:

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Phone of Relative or Friend:

(optional)

How did you learn of our program?*

Other:

Program Schedule

Please identify the program in which you are requesting enrollment.

Program

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.