Lung Screening Appointment Request Form 
You may qualify for a low-dose CT lung cancer screening if you meet the following criteria:
  • 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 lung screening nurse navigator will reach out to you to coordinate next steps.
The Christ Hospital