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, all of our online forms are encrypted and stored in a secure location. Please note that 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.

First Name * Middle Initial 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 * Insurance Provider 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 How did you hear about us? Google Search Houston Methodist web site Television Newspaper ad Radio Direct mail/flyer Physician Nurse Friend/family member Other I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters. Yes

Authentication *