Lung Cancer Screening Form

Roswell Park’s Lung Cancer Screening Program is for people who are concerned about their risk of developing lung cancer.

Answer the questions below to help our lung cancer experts assess your risk level for lung cancer.

* indicates required field

Tobacco Use
If no, please proceed to question #8.
years
packs per day
Contact Information

You have completed the Lung Cancer Screening Form. In order to determine your eligibility for the Screening Program, please fill out the form below to submit your assessment to an RPCI cancer information specialist. You may also contact them at 1-877-ASK-RPCI (1-877-275-7724) to do an over-the-phone evaluation.

HIPAA: Patient Privacy

Due to HIPAA regulations, Roswell Park will not be able to identify itself to someone other than you who may answer the phone or in a voice message, unless you indicate otherwise.