Logo Horizontal
CT Lung Assessment

Specialist Lung Assessment Evaluation Form

Please complete our Specialist Lung Assessment Evaluation Form and our patient care team will be in touch to book your appointment.

Specialist Lung Assessment Evaluation Form

dd/mm/yyyy

NHS GP

It is a requirement that we communicate results to your NHS GP in order that they can make recommendations about your future care. By submitting this form you acknowledge and accept that:

- A copy of your report will be sent to your GP
- Neither the radiographer who has conducted the scan/form or the radiologist reporting it can discuss the findings of the scan with you.

If known
Do you have any pre-existing medical conditions?
Did you have a positive COVID-19 swab test?
Did you have a positive COVID-19 antibody test?
Do you have any ongoing/persistent symptoms as a result of COVID-19? cough, breathlessness, palpitation, chest soreness
Have you had a CT scan of the chest in the last 3 months?
Are you a current or past smoker?
Do you have a family history of lung cancer?

Specialist Lung Assessment terms and conditions

Increasingly patients wish to take greater control of their own health and are becoming more aware of the opportunities to self-investigate their health issues, or simply reassure themselves that they are well.

To this end, Vista Health welcomes patients (“you”) who wish to refer themselves for a Specialist Lung Health Assessment. You need to be aware of and agree to the following important information prior to proceeding with a self-referral booking:

  1. Scans will only be offered to all those aged 35 and above.
  2. You will need to complete a Specialist Lung Health Assessment, detailing the reasons why you wish to have a scan. If it is for a medical complaint, this should be self-documented. If it is for reassurance, that too should be stated.
  3. We will not accept self-referrals from you if you are engaged in professional sports or for anything connected with a professional sports club of which you are a member.
  4. Scans will only be performed on the areas which we routinely scan. The self-referral form will be protocolled and you will be advised if we are unable to proceed with the requested examination.
  5. Self-referrals will not be accepted if you have cancer or a long term medical condition related to the area of concern.
  6. You accept you are solely responsible for selecting the area you want to be scanned and that you are not relying on any input in this regard, whether clinical or otherwise, from Vista Health.
  7. You must be registered with an NHS GP, to whom a copy of the report will be sent and with whom all discussions about your future care must take place. We cannot enter into any such discussions with you.
  8. We cannot perform scans if you cannot, or do not wish to provide the name of your GP.
  9. You will be required to complete a safety questionnaire at the time of booking which may exclude you from proceeding with the scan or delay it, depending on the information you provide. It is very important that you tell us about anything which could affect our ability to scan you safely.
  10. If you require further information or would like to query the content of the report, the request must be raised by a GP or medical professional.
  11. You must understand that CT scans may on occasion identify unexpected abnormalities which may or may not require further investigation. If so, these findings will be identified on the report and any recommendations arising will be followed up by your GP.
  12.  You may bring a friend or relative with you, who may, if required, stay with you for the scan itself, subject to safety checks. Unfortunately, you may not bring children under the age of 16 to accompany you.
  13.  If you cancel your appointment with less than 48 hours’ notice charges will occur that you will have to pay. This will be subject to discretion for unavoidable absence due to illness, travel disruption etc.
  14. The NHS and private medical insurance companies will not fund or cover self-referrals. All self-referrals are undertaken on a self-pay basis only.
  15. You accept that the General Patient Terms and Conditions (as provided to you in your appointment pack) apply to the services provided to you by Vista Health.
  16. Please note certain sites have specific age restrictions.