Contact the Tobacco Dependence Clinic

Please fill out this form, and someone from our staff will contact you within the next week.
If you prefer, you may contact us by phone at (732) 235-8222.

If you have a medical emergency, please dial 911.

All information that you provide on this form will be kept private.

What is your name?
   
How may we contact you?
Daytime Phone
Evening Phone
Email Address:
   
Reason(s) for contact:
I want help to quit smoking or smokeless tobacco
Other (Please explain)
   
How did you hear about us?
Brochure or Pamphlet
Friend, Family Member or Co-Worker
Health Care Provider
Health Fair or Community Event
I am a former patient
Internet Search
Newspaper Ad
Other (Please explain):
   
Please provide any additional information here:

We Can Help You Quit!
UMDNJ-Tobacco Dependence Clinic | 317 George St., Ste 210, New Brunswick, NJ 08901 | T: 732-235-8222 | F: 732-235-8298 | Contact Us