Lung Cancer Screening

Please complete this form to determine your eligibility for a lung cancer screening. Call (844)-CHS-LUNG (844-247-5864) or email LUNG@chsli.org if you have any questions.

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Contact Information

First Name *

Last Name *

Best Contact Phone Number *

Email Address *

Smoking Information

Are you 55 to 77 years of age? *

Yes

Do you currently smoke or have you quit within the last 15 years? *

Yes

How many years have you smoked? *

On average, how many packs of cigarettes do you or did you smoke per day? *

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Lung Cancer Screening