Evanston Department of Health and Human Services
Nicotine Addiction Seminar
Online Registration Form
Last Name :
First Name :
Address :
City :
State :
Zip Code :
Home Phone :
Work Phone :
Email :
Years Smoked :
(Must have a number entered to submit)
Cigarettes per Day :
(Must have a number entered to submit)
Any Smoking-Related Medical Conditions :
no
yes
Where you first heard about the clinic :
choose one
Skokie Health Department
Evanston Health Department
Physician
Dentist
Evanston Review
Skokie Life
Evanston Round Table
Clinic Graduate
Skokie Chamber of Commerce
Evanston Chamber of Commerce
Evanston Cable
Skokie Cable
Internet Site
Local Hospital
E-mail
Poster Flyer
Century Theater Movie Screen
other
Notes :