Registration

When you pre-register online, you automatically qualify for a ten percent discount off current tuition rates when you join X Smokers.

All questions must be answered to register.
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How did you hear about X Smokers?


Do You Smoke?
Yes, I smoke. I don't smoke, I am entering for a friend.

Average number of cigarettes you smoke per day:


Your age:
19-25 26-35 36-45	46-55 56-65 Over 65

How many times have you tried to quit before?


What have you tried?
COLD TURKEY HYPNOSIS ACUPUNCTURE NICOTINE PILLS NICOTINE GUM NICOTINE PATCH NICOTINE INHALER	LASER TREATMENT ZYBAN CHANTRIX LIFESIGN® COMPUTER DEVICE ONLINE PROGRAM LUNG ASSOCIATION COUNTY HEALTH UNIT

Tried Something Else:

I want to quit because: