Schedule a CT Lung Screening

Physician Name (First & Last)

Physician Address

Name

Date of Birth

/ /

Phone Number

E-Mail Address

Insurance

If other insurance please specify

Do you have orders from your doctor?

Are you 50-77 years of age and in fairly good heath?

Do you currently smoke or are a former smoker who has quit within the past 15 years?

Do you have a 20 pack-year history (1 pack a day for 20 years or 2 packs a day for 10 years)

Material contained within this website is for informational purposes only and is not intended as professional medical advice, diagnosis or treatment.