Lung Appointment Request Form
If you meet the following criteria, you MAY QUALIFY FOR A LOW-DOSE CT LUNG CANCER SCREENING:
- Age 55 - 77
- Have no signs or symptoms of lung cancer
- Are a current smoker or have quit within the last 15 years
- Have a tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes)
- Complete this form and our nurse navigator will help coordinate next steps.