Lung Screening Patient Form | Clearview Cancer Institute

Skip to content

New Patient Forms
Donate
Locations
Careers
Contact

Menu

New Patient Forms
Donate
Locations
Careers
Contact

YOUR VISIT
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.

About / Why Clearview

What to Expect on First visit

New Patient Paperwork

FAQ’s

Preparing For Appointments

Financial Services and Insurance

Locations
YOUR TEAM
Learn more about the Board Certified physicians at Clearview Cancer Institute and what distinguishes Clearview as the region's leading cancer treatment facility.

Our Physicians

Advanced Practice Providers

Administrative Staff
YOUR CARE
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.

Diagnostic Imaging

Genetic Counseling

Genetic Testing

Genomic Testing

Hematology

Lab Services

Medical Oncology

Radiation Oncology

Therapy Services

Huntsville Hospital Outpatient Medical

Pharmacy
YOUR RESOURCES
Understanding your options for cancer treatment can feel overwhelming. Clearview Cancer has all the resources you need to help you and your loved ones navigate and fully comprehend your treatment.

Cancer Types

Educational Classes

Managing Side Effects

Cancer Prevention

Lung Cancer Screening

Research and Clinical Trials

Cancer Treatment

Volunteer Opportunities

Share Your Story

The Quest Blog

Confidence with a Clear View

Videos

Financial Services

Social Services

Support Groups

Physician Referrals

Pay Your Bill Online

You are here:

Lung Screening Patient Form

Locations

Huntsville – Crestwood

Huntsville – Russel Hill

Lung Cancer Screening - Patient Form

Patient Form

Fields marked with an * are required

Contact Information

Contact Information

Full Name *

Nickname

Street Address *

City *

State *

Zip *

Home Phone *

Cell Phone

May we leave you a message?

Yes
No

Email Address *

Insurance

Demographic Information

Demographic Information

Date of Birth *

Gender *

Female
Male

Race/Ethnicity

Screening

Screening

SMOKING STATUS *

Current
Former
Never Smoked

HAVE YOU SMOKED WITHIN THE PAST 15 YEARS? *

Yes
No

ARE YOU HAVING SYMPTOMS OF LUNG CANCER SUCH AS SHORTNESS OF BREATH OR COUGH? *

Yes
No

ARE YOU AGE 50 - 80? *

Yes
No

ARE YOU ABLE TO LAY FLAT FOR MORE THAN 15 MINUTES? *

Yes
No

I hereby release the undersigned to release information acquired in the course of my examination or treatment to insurance companies or authorized physicians. *

I hereby authorize payment directly to the North Alabama Oncology and/or Oncology Specialties, of the medical and/or emergency medical benefits, including major medical insurance, if any, otherwise payable to me for this service as described below. I understand that I am financially responsible for the charges not covered by this authorization. *

PLEASE CHECK THE BOX

If you are a human seeing this field, please leave it empty.

Your Resources

Cancer
Treatment

UNDERSTAND TREATMENT OPTIONS

Your Resources

Clinical
Trials

Revolutionizing Cancer Care

Your Resources

Lung
Screening

Why Screening Saves Lives

Cancer Doctors
Support Groups
Volunteer Program

For Patients

Cancer Treatment
Lung Screening
First Visit
Pay Your Bill
Maps & Directions
Navigating Care Portal

PHYSICIAN REFERRALS

Fax Referral Form
Online Referral Form

ABOUT CLEARVIEW

Cancer Doctors
Pharmacy
Diagnostic Imaging
Genetic Testing
Lab Services
Events
Donate
Volunteer Program
Transparency in Coverage

LOCATIONS

Anniston
Athens
Cullman
Decatur
Huntsville - Crestwood
Huntsville - Russel Hill
Jasper
Madison
Scottsboro
Shoals

888-374-1015

ALL RIGHTS RESERVED
PRIVACY POLICY
BILLING DISCLOSURES
PATIENT RIGHTS
NON-DISCRIMINATION STATEMENT
LANGUAGE ASSISTANCE SERVICES

Facebook Instagram Linkedin

All Content © 2025 Clearview Cancer Institute

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:

PLEASE CHECK THE BOX

If you are a human seeing this field, please leave it empty.

0

We use cookies to optimize our website and our service.

Functional Functional Always active

The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.

Preferences Preferences

The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.

Statistics Statistics

The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.

Marketing Marketing

The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.

Manage options Manage services Manage {vendor_count} vendors Read more about these purposes

Preferences

{title} {title} {title}