Directions:Please register your medical facility and confirm your QuitManager access information by providing a brief response in the fields below.
Medical Facility Registration Form
Health Professional First Name*:
Health Professional Last Name*:
Address*:
Address2:
City, State Zip*:
Telephone Number*: (10-digits, no dashes)
Email*:
Name of Medical Center*:
Organization IVR Name*:
* = required field
Health Professional Login and Password for QuitManager Access
Enter Your Login Name*: (above email address) Create a Password*: (Minimum of 6 characters) Re-enter your  Pasword*: (Minimum of 6 characters) Registration Key*: (contact PICS research staff for assistance if unknown)
* = required field