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    Registration Request - Intensive Tobacco Treatment Program

    Intensive Tobacco 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
    (optional)Mayo Clinic Number: must have at least 0 and no more than 256 characters.The value of the Mayo Clinic Number: field is not valid.
    (optional)
    Please enter your first namePlease enter your first name
    *
    (optional)Middle Name: must have at least 0 and no more than 256 characters.The value of the Middle Name: field is not valid.
    Please enter last namePlease enter last name
    *
    Please ensure the email address is valid and follows the standard format — for example, johndoe@isp.com.
    *
    *
    (optional)
    (optional)Maiden Name: must have at least 0 and no more than 256 characters.The value of the Maiden Name: field is not valid.
    (optional)Spouse Name: must have at least 0 and no more than 256 characters.The value of the Spouse Name: field is not valid.
    (optional)Previous Married Name: must have at least 0 and no more than 256 characters.The value of the Previous Married Name: field is not valid.
    (optional)Former Spouse Name: must have at least 0 and no more than 256 characters.The value of the Former Spouse Name: field is not valid.
    *
    *
    Please enter your AddressPlease enter your Address
    *
    Please enter your CityPlease enter your City
    *
    Please enter your State/ProvincePlease enter your State/Province
    *
    Please enter your Postal CodePlease enter your Postal Code
    *
    Please enter your Home Phone numberPlease enter your Home Phone number
    *
    (optional)Cell Phone: must have at least 0 and no more than 256 characters.The value of the Cell Phone: field is not valid.
    (optional)Work Phone: must have at least 0 and no more than 256 characters.The value of the Work Phone: field is not valid.
    (optional)
    (optional)Name of Nearest Living Relative or Friend: must have at least 0 and no more than 256 characters.The value of the Name of Nearest Living Relative or Friend: field is not valid.
    (optional)Relationship: must have at least 0 and no more than 256 characters.The value of the Relationship: field is not valid.
    (optional)Home Address of Relative or Friend - Street must have at least 0 and no more than 256 characters.The value of the Home Address of Relative or Friend - Street field is not valid.
    (optional)City, State, ZIP Code: must have at least 0 and no more than 256 characters.The value of the City, State, ZIP Code: field is not valid.
    (optional)Enter a valid telephone number.
    How did you learn of our program?
    *
    Please enter your Other informationPlease enter your Other information
    Program Schedule
    *

    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.

    Mayo Clinic Number

    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:

    In correspondence:

    Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

    In pre-appointment questionnaires

    Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

    In medical documents:

    Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

    In dismissal summaries:

    Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

    In several other kinds of documents:

    Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information
    .

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