Houston Methodist Lung Cancer Screening Interest Form

Houston Methodist provides patients with expert care for the detection and treatment of lung cancer, including access to expert physicians, state-of-the-art technology and advanced treatment options. To learn more about our Lung Cancer Screening Program or to find out if you qualify, complete the form below. A representative will contact you within two business days.

To protect your privacy our online form data is encrypted and stored in a secure location. Please note, while our forms are secure, any communication via e-mail may not be secure, so please consider that when selecting a way for us to contact you.

 

*denotes required field

First Name * Last Name * Address * City * State * AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Postal code * Daytime Phone Number * Date of Birth * Email Address *

Are you a current or former smoker?

Yes No

If you are a current smoker, how many years have you been a smoker?

If you are a former smoker, did you quit less than 15 years ago?

Yes No

What is your preferred Houston Methodist location? Houston Medical Center Baytown Hospital Clear Lake Hospital – Bay Area Comprehensive Care Center - Pearland Sugar Land Hospital West Hospital – West Houston Imaging Center – Katy Freeway Willowbrook Hospital - Northwest Houston The Woodlands Hospital

How would you prefer to be contacted?

Email Phone

I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.

Yes

Authentication *