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.