Lung Screening Van Location Request
Thank you for your interest in hosting a lung screening event with the Siteman Lung Screening Van. Our mobile lung screening unit travels throughout the St. Louis region and surrounding communities, providing lung cancer screenings to eligible individuals, regardless of insurance or income. After you submit the form below, a member of our team will contact you to discuss your request and the next steps.
Organization Name
*
Organization Contact
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested Screening Event Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Will our staff be able to access indoor bathrooms during the screening day?
*
Yes
No
To help us prepare for your event, and provide an excellent experience for your attendees, please let us know if you anticipate a large percentage of any of attendees who:
*
Speak English as a second language
Are receiving their first ever mammogram
Are uninsured or underinsured
All of the above
None of the above
Is this request for a special event? (Health fair, 5K, etc.)
*
Yes
No
Does the location have a flat and level surface for parking (such as a parking lot or street)?
*
Yes
No
If the location requires a parking permit from the city, you may be expected to take additional steps to ensure parking for the day/event. Does the location require a parking permit?
*
Yes
No
Unknown
Submit
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