National Lung Cancer Screening Program

National Lung Cancer Screening Program

IMAGING REQUEST
Patient Details
Title*
First Name*
Enter ONLYNAME for patients with one name
Last Name*
Date of Birth*

DayMonthYear
Date
Email
Aboriginal/Torres Strait Islander Origin
Phone*
Best Contact Phone
Select Imaging Site*
This request will be sent to this PRP practice
Clinical Details
Participant screening type*

Initial (First Scan)Returning / Follow-up
Interval Scan as determined by previous findings

1 mth2 mth3 mth6 mth12 mth
Participant smoking status

Never smokedCurrent smokerFormer Smoker
History (Choose if applicable)

Prior chest CTFamily history of lung cancerAny cancerAny COPD
Only required for first/baseline LDCT
(First-degree relatives include parents, siblings or children)
Date of Imaging

DayMonthYear
Radiology Provider/Location if known
Please provide details of cancer history
Additional clinical / other notes, if required
Referring Doctor Details
Title*
First Name*
Last Name*
Provider Number*
Practice Name/Institution*
Phone*
Best Contact Phone
Email*
Eligibility*

I confirm this patient meets the eligibility criteria of the National Lung Cancer Screening Program
Gender
Patient Full Name
Referrer Fullname
Study Description
Should be Empty: