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Suggest a Doctor or Hospital join StopSmokingDoctors.com

As a smoker and member of your community you are in a unique position to understand the needs of your community. You may be aware of a doctor (perhaps your doctor), hospital or medical center that should offer a stop smoking program. You can suggest to a hospital or doctor that they establish a state of the art, successful smoking cessation program by using the form below. Your personal information will be kept confidential.

Please provide the following contact information for a possible addition to the StopSmoking Doctors or Hospital database. Database Listing is free. Your personal information will be held in the strictest confidence.

* Information is required

*Doctor or Hospital Name
*Your Name (Your name will be kept confidential)
*Are you a patient of this Doctor or Hospital?
Doctor or Hospital Street Address
Address (cont.)
*City
*State
Zipcode
Doctor or Hospital Phone Number
*In the future, would you like to be informed of Stop Smoking Doctors or Hospitals in your area?
*Your email address
Your Home Phone
Your Home Address
Your Home Address (2nd line)
*Your City
*Your State
Your comments

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Suggest a Doctor or Hospital join StopSmokingDoctors.com

Copyright © 2003 [Smoking Consultation Service]. All rights reserved. Revised: 12/04/03

Copyright © 2003 [Smoking Consultation Service]. All rights reserved.
Revised: 12/04/03