Your personal information, including results of low dose CT scans and other CT imaging completed for the purposes of screening as part of the NLCSP, may be shared between your treating healthcare providers for the purposes of the NLCSP. For example, if you attend different radiology providers for your first low-dose CT scan and your second low-dose CT scan, the first radiology provider may disclose your low-dose CT images to the second radiology provider to facilitate comparison of the results of the two low-dose CT scans. By participating in the NLCSP, you consent to the use of your personal information by healthcare providers, specialists and radiologists, for the purposes of the program, and the disclosure and collection of your personal information between healthcare providers, specialists and radiologists for the purposes of the program.

PATIENT DETAILS (or affix label)

Patient Name:

DOB:

Phone:

Address:

Medicare Number:

Aboriginal/Torres Strait Islander Origin:	No	Yes, Aboriginal	Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander	Prefer not to answer

CLINICAL INFORMATION

This patient meets the eligibility criteria of the National Lung Cancer Screening Program

Type of screening test:
2 yearly scan: New participant	OR Participant returning for two-year scan
OR
Interval scan to monitor previous findings (1, 2, 3, 6 or 12 month interval scan as determined in previous NLCSP LDCT report)

Any previous Chest CT (if known) Date:	Radiology provider/location: (if known)

Family history of lung cancer in a first-degree relatives (only required for first/baseline LDCT)
(First-degree relatives include parents, siblings or children)

History of any cancer (if yes, provide details) 	

Additional clinical / other notes, if required

REQUESTING PRACTITIONER (or affix label)

Name:

Provider Number:

Phone:

Address:

Fax:

Signature:

Date:

Send copy to: