Lung Appointment Request Form

If you meet the following criteria, you MAY QUALIFY FOR A LOW-DOSE CT LUNG CANCER SCREENING:

• Age 50 - 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 20 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.