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If you'd like to receive more information about CHANTIX, please fill out the information below. You will not receive additional information unless you specify your request below the privacy statement.

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*First Name:
*Last Name:
*Address 1:
Address 2: (apartment or suite number):
*Zip Code:
Phone (example: 123-456-7890):
Are you requesting information for yourself or for someone else? Due to the personal nature of the materials and Pfizer's respect for the privacy of personal medical information, we can only send the materials directly to you.
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Are you currently taking CHANTIX?



*In what year were you born? (For example, 1967)

Privacy Statement

Pfizer understands your personal and health information is private. The information you provide will only be used by Pfizer and parties acting on its behalf to send you the materials you requested and other helpful information and updates on CHANTIX, GETQUIT and/or smoking cessation as well as related treatments, products, offers and services.

By checking this box, I also agree that Pfizer or companies acting on its behalf may send me materials about other health conditions, use my information to develop or improve products and services, or contact me in the future about health-related topics.