Swedish Lung Cancer Screening Contact Form

Thank you for your interest. Please share some information about yourself and someone from our team will contact you.

First Name*

Last Name*

Email Address*

Phone Number*

Address*

City*

State*

ZIP code*

What is your preferred method of communication for our liaison to contact you?

Phone

Best day/time to call

Date of Birth*

Gender*

Male

Female

Prefer not to answer

Referring Physician Name (if applicable)

Do you have previous chest imaging?

Yes

Do you have a history of smoking?

Yes

If yes, how many cigarettes do you or have you smoked on average per day?

If yes, how many years have you smoked?

If you no longer smoke, when did you quit?

Provide approximate month/year.

Please let us know if you have any additional questions.