Lung 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.

Contact Information

Are you the patient? *

Have you ever been seen at Roswell Park Cancer Institute?


Has this individual ever been seen at Roswell Park Cancer Institute?

Would you like to join our mailing list?

Patient's Contact Information
Eligibility

Have youHas the patient ever been treated for cancer of the head or neck, lung or esophagus?



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.


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 Sate Smoking Quite Line (NYSSQL) at 1-866-697-8487