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.


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