Lung Cancer Webinar - Screening Request

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.

I would like to speak with a Lung Nurse Navigator about:

First Name*

Last Name*

Email Address*

Primary Home Phone*

Preferred Method of Contact*

Former or Current Smoker?*

Age*

How many years have / did you smoke?*

How many packs do / did you smoke per day?*

How did you hear about us?*

By submitting this form, I accept the privacy policy and terms of use.**

I understand that The Christ Hospital Health Network may contact me via telephone or email about healthcare services using an automated technology.

MAIN CAMPUS

2139 Auburn Avenue

Cincinnati, OH 45219

513-585-2000

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