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
Interval Scan as determined by previous findings
Participant smoking status
History (Choose if applicable)
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
Gender
Patient Full Name
Referrer Fullname
Study Description
Should be Empty: