Lung Cancer Screening

Patient First Name *

Please let us know your name.

Middle Name

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Patient Last Name *

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Patient Gender

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Patient Street Address

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City

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County

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State

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Zipcode

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Is the patient a current or former smoker? *

YesNo

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Has the patient smoked within the past 15 years? *

YesNo

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Is the patient having symptoms of lung cancer such as shortness of breath or cough? *

YesNo

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Is the patient age 55-77? *

YesNo

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Patient Date of Birth *

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Patient Preferred Contact Phone Number (include area code) *

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May we leave patient a message?

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Patient Email *

Please let us know your email address.

Is patient able to lay flat for more than 15 minutes? *

YesNo

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For Physician Office Use Only

Referring MD *

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Specialty

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NPI number

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Tax ID#

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Office Street Address

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City

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County

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State

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Zipcode

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Office Phone (include area code) *

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Office fax

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Office contact

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Direct phone line

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Type of CT Scan ordered

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MRI of

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Reason for Scan

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Please check the box *

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