Stop Smoking Registration - Hypnosis by Doctors :Hypnosis by Doctors

Stop Smoking Registration

You will be contacted for an appointment when we receive your completed form.

Please review the testimonials after submitting your form.

Date*
Month
Day
Year
First Name*
Last Name*
DOB*
Month
Day
Year
Age*
Marital Status*
Occupation*
Email*
Phone*
Please choose one of the following below:
- I would rather have a phone consultation
- I would rather have a zoom consultation
Consultation Fee*
Price:
Once you make this payment complete the second half of the form that asks details about your lifestyle problem. All information is confidential and only seen by Dr. Smith.
Credit Card*
WE DO NOT RETAIN CREDIT CARD INFORMATION!

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Please Return to the Registration Page and See Testimonials Before Your Appointment.

Please review the stop smoking endorsements and call the office.

WEIGHT LOSS

PAIN & MIGRAINE

STOP SMOKING

ANXIETY & DEPRESSION

ALCOHOL & DRUGS

GAMBLING

Dr. Clinton W. Smith, Psy.D

Clinical Psychologist & Hypnotherapist

For Assistance:

Call Us: (334)233-5610
Email Us: DrClintonwSmith@gmail.com
Office Address: 495 St. Luke Drive Montgomery, AL 36117

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