Lung Cancer Risk Assessment

Please be aware this program is usually covered by insurance, however, you may be responsible for a copay. If your insurance requires a referral, you will need to obtain one from your doctor.

To determine if this program is appropriate for you please answer a few brief questions.

Please complete the assessment below to determine if this program is appropriate for you. If you are eligible, a referral specialist will contact you within two business days to gather more detailed information.

Fields marked with an asterisk * are required.

Personal Information

About You

Are you calling for yourself, or on behalf of someone else? *

About The Patient

Have you Has the patient ever been seen at Roswell Park?

General Information

Your The Patient's Contact Information

Would you  the patient like to join our mailing list?

Your Patient's Residential Address

Your Patient's Insurance Information Optional

Your The Patient's Physician Information Optional

Risk Assessment

Prior Cancer Treatment

Have youHas the patient ever been treated for cancer of the head or neck, lung or esophagus? * Please note, this excludes cancer of the thyroid.
Please indicate which type of cancer you havethe patient has received treatment for: *

Smoking History

Do youDoes the patient now, or have youhas the patient ever smoked cigarettes? *

Please enter how many cigarettes smoked per day by the number of years.
(There are 20 cigarettes in a pack)

Please utilize additional boxes if your smoking history has ever changed. If it has not changed, please leave the below blank.

If pack years are at least 20, ELIGIBLE
Have youHas the patient smoked within the last 15 years? *
Are youIs the patient interested in stopping smoking? *

For additional smoking cessation tips please call the New York State Smoking Quit Line (NYSSQL) at 1-866-697-8487


Are youIs the patient an active firefighter? *
Are youIs the patient an employee of Gernatt? *

Please choose a preferred location for the appointment *