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Lung Cancer Screening Program (LCSP)

LCSP Referral Form →

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Home
Topics
About Us
Questions & Answers
Contact Us
Our MDM
Smoke cessation clinic
English
- Persian
- Chinese (Simplified)

LCSP Referral Form →

LCSP Referral Form

Download PDF Form

Fill all required fields (★) to submit the form.

Patient details:

Full Name:(Required)

Prefix First Last

Preferred name:

Date of birth:(Required)

DD slash MM slash YYYY

Mobile Number:(Required)

Home Phone:

Address:

Email address(Required)

Please choose your preferred location:

Clinic:(Required)

RSDC Ferntree Gully
719 Burwood Hwy, Ferntree Gully VIC 3156

RSDC Epworth Camberwell
Suite 2 Epworth Camberwell, 888 Toorak Rd, Camberwell VIC 3124

RSDC Knox
Suite 2a Knox Private Hospital, 262 Mountain Hwy, Wantirna VIC 3152

RSDC Balwyn North
345 Doncaster Rd, Balwyn North Vic 3104

RSDC Richmond
2a, Bridge Rd, Richmond Vic 3121

Diagnostic Request

Diagnostic Services Requested(Required)

Low Dose non contrast CT Scan of Chest for Lung Cancer Screening (MBS Item Number 57410)

Follow-up Low Dose non contrast CT Scan of Chest for Lung Cancer Screening (MBS Item Number 57413)

📋

MBS Item Numbers - NLCSP

The MBS item numbers for the National Lung Cancer Screening Program (NLCSP) are:

57410

Initial low-dose CT scan

57413

Follow-up/interval scans

Important: These items are mandatory bulk-billing and exempt from certain CT fee adjustments.

Referral Details

Reason for Referral and Clinical History(Required)

Patient meets criteria for LCSP

I consent to my CT Scan findings be discussed in Multi-Disciplinary Meeting (MDM), if it was thought to be necessary and the results be communicated with my referring doctor

Referring Practitioner's Details

Practitioner's Name

Provider Number

CC

To be Filled by Patient

Age: 50-70 years old?

Yes

No

Any Symptoms?

Yes

No

Symptoms:(Required)

Breathlessness

Cough

Phlegm

Chest pain or discomfort

Wheeze

Weight loss

Others

Others (include):(Required)

Current Smoker?

Yes

No

If you stopped smoking, did you stop less than 10 years ago:

Yes

No

Packsmeter (Pack-Years):

📊 Please refer to the Pack Years calculator below:

🔗 Calculate Pack Years

Have you had a CT Scan of chest within last 12 months?

Yes

No

Confirm:(Required)

I consent to my CT Scan findings be discussed in Multi-Disciplinary Meeting (MDM), if it was thought to be necessary and the results be communicated with my referring doctor.(Required)

Lung Care Centre (LCSP)

At LCSP, we provide evidence-based lung screening aligned with Australian guidelines. Our expert team of respiratory physicians, radiologists, oncologists, thoracic surgeons, nurses, and researchers ensures careful assessment of positive CT results to minimize misdiagnosis and unnecessary procedures.

Email: admin@lungcare.au
Phone: 1300 773 210

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