Lung Cancer Screening Doctor Form | Clearview Cancer Institute

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Learn what to expect and how to prepare for your first visit to Clearview Cancer Institute. Find your location and explore the FAQ's section for answers to many common questions.

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Clearview Cancer Institute offers every service and amenity needed in an outpatient setting. Our Phase I-IV clinical trials and relationships with renowned institutions place Clearview in a unique position to provide leading-edge care.

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Lung Cancer Screening Doctor Form

Locations

Huntsville – Crestwood

Huntsville – Russel Hill

Lung Cancer Screening - Physician Referral Form

Physician Form

Fields marked with an * are required

Contact Information

Contact Information

Patient Full Name *

Patient Street Address *

Patient City *

Patient State *

Patient Zip *

Patient Home Phone *

Patient Cell Phone

May we leave patient a message?

Yes
No

Patient Email Address *

Patient Insurance

Demographic Information

Demographic Information

Patient Date of Birth *

Patient Gender *

Female
Male

Patient Race/Ethnicity

Screening

Screening

PATIENT SMOKING STATUS *

Current
Former
Never Smoked

HAS PATIENT SMOKED WITHIN THE PAST 15 YEARS? *

Yes
No

IS PATIENT HAVING SYMPTOMS OF LUNG CANCER SUCH AS SHORTNESS OF BREATH OR COUGH? *

Yes
No

IS PATIENT AGE 50 - 80? *

Yes
No

IS PATIENT ABLE TO LAY FLAT FOR MORE THAN 15 MINUTES? *

Yes
No

For Physician Office Use Only

For Physician Office Use Only

REFERRING MD *

SPECIALTY

NPI NUMBER

TAX ID#

OFFICE STREET ADDRESS

CITY

COUNTY

STATE

ZIPCODE

OFFICE PHONE (INCLUDE AREA CODE) *

OFFICE FAX

OFFICE CONTACT

DIRECT PHONE LINE

CT Scan Options

Initial Lung Cancer Screening
Annual Lung Cancer Screening
Diagnostic Lung Cancer Screening

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ABOUT CLEARVIEW

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LOCATIONS

Anniston
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Fields marked with an * are required

Full Name *

Date of Birth *

Mailing Address

Mailing Address

Street Address *

City *

State *

Zip *

Best way to contact?

Phone
Email

Phone *

Email Address *

Demographic Information

Demographic Information

Age

Gender *

Female
Male

Race

CCI MD

Select Class Date *

Wednesday, March 5, 9:30am - Singer River Cancer Center

Referred to the Confidence with a Clearview workshop by:

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