Jefferson University Hospitals

Preparing for Your Visit

Before your appointment with the Smoking Cessation and Counseling Therapy Program, please print and fill out this Assessment Form (PDF) and bring it with you.

Registration Forms for New Patients

Once you schedule an appointment, please print and fill out the New Patient form and bring it with you. The paperwork consists of:

  • Registration Form
  • Medical Health Questionnaire
  • Healthcare Provider and Pharmacy Information Sheets
  • Jefferson University Physicians Communication of Protected Health Information

Our patient office is located on the 5th floor of the Medical Office Building at 1100 Walnut Street, Philadelphia. 

Other Items to Prepare

 When you come to your appointment, be sure to bring the following:

  • Any additional information forwarded by your regular physician
  • Your insurance card, with ID number and group number
  • Your pharmacy/prescription benefit card
  • Means to make any in-office co-payments necessary

Before and during your visit, think about what questions you need to have answered. This may include information about:

  • Staging of your condition
  • Side effects of treatment
  • Next steps in care
  • Medications
  • Follow-up
  • Limitations after treatment

Thank you for taking the time to prepare for your appointment. We are looking forward to seeing you.