print form		 NY Hypnosis & Laser Center, Ltd.

 Smoker's List
email:
First Name:
Last Name:
Phone:

List 4 times when you felt totally disgusted about smoking:

1.
2.
3.
4.

List all the reasons you have for wanting to stop smoking:

1.
2.
3.
4.
5.
6.

List all the benefits you will get from being a non-smoker:

1.
2.
3.
4.
5.
6.
       

NY Hypnosis & Laser Center
is The Personal Change Place.  Tell your friends.

© 2003 NY Hypnosis & Laser Center
4160 S. Ft. Apache Road-Ste B
(within Madame Et Monsieur)
Las Vegas, NV 89147

Tel: 702-454-7910  Fax: 702-507-2335