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<p>Silver Cross Hospital provides patients with expert care for the detection and treatment of lung cancer, including access to expert physicians, state-of-the-art technology and advanced treatment options. To learn more about our Lung Cancer Screening Program or to find out if you qualify, complete the form below. A representative will contact you within two business days.</p><p>To protect your privacy, all of our online forms are encrypted and stored in a secure location. Please note that while our forms are secure, any communication via e-mail may not be secure, so please consider that when selecting a way for us to contact you.</p>\
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</div></div><div class=\'form-group\'><label  class=\'control-label  \'>Are you a current or former smoker?</label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Yes\'  name=\'checkbox11\' id=\'FormField11_32358840-34c2-4ff4-aadd-7a0b37933eb6_1\' class=\'right\' data-export-label=\'Current_or_former_smoker\' ><label for=\'FormField11_32358840-34c2-4ff4-aadd-7a0b37933eb6_1\'>Yes</label></div><div class=\'flow\'><input type=\'radio\' value=\'No\'  name=\'checkbox11\' id=\'FormField11_32358840-34c2-4ff4-aadd-7a0b37933eb6_2\' class=\'right\' data-export-label=\'Current_or_former_smoker\' ><label for=\'FormField11_32358840-34c2-4ff4-aadd-7a0b37933eb6_2\'>No</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField21_32358840-34c2-4ff4-aadd-7a0b37933eb6\' class=\'control-label  \'>If you are a current smoker, how many years have you been a smoker?</label><div>\
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</div></div><div class=\'form-group\'><label  class=\'control-label  \'>If you are a former smoker, did you quit less than 15 years ago?</label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Yes\'  name=\'checkbox22\' id=\'FormField22_32358840-34c2-4ff4-aadd-7a0b37933eb6_1\' class=\'right\' data-export-label=\'former_smoker_quit_less_than_15_years\' ><label for=\'FormField22_32358840-34c2-4ff4-aadd-7a0b37933eb6_1\'>Yes</label></div><div class=\'flow\'><input type=\'radio\' value=\'No\'  name=\'checkbox22\' id=\'FormField22_32358840-34c2-4ff4-aadd-7a0b37933eb6_2\' class=\'right\' data-export-label=\'former_smoker_quit_less_than_15_years\' ><label for=\'FormField22_32358840-34c2-4ff4-aadd-7a0b37933eb6_2\'>No</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField20_32358840-34c2-4ff4-aadd-7a0b37933eb6\' class=\'control-label  \'>What is your preferred Silver Cross location?</label><div><select  name=\'FormField20_32358840-34c2-4ff4-aadd-7a0b37933eb6\' id=\'FormField20_32358840-34c2-4ff4-aadd-7a0b37933eb6\' class=\'form-control \' style=\'width: auto\'  data-export-label=\'What_is_your_preferred_Silver_Cross_location\' ><option value=\'\' selected>( Please Select )</option><option value=\'Silver Cross Hospital (New Lenox)\'>Silver Cross Hospital (New Lenox)</option><option value=\'Silver Cross Health Center (Homer Glen)\'>Silver Cross Health Center (Homer Glen)</option><option value=\'Prime Medical Imaging (Mokena)\'>Prime Medical Imaging (Mokena)</option></select></div></div><div class=\'form-group\'><label  class=\'control-label  \'>How would you prefer to be contacted?<span class=\'fb-required\'>*</span></label><div><div><fieldset class=\'CheckboxGroup\'><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Email\' required data-msg-required=\'How would you prefer to be contacted? is required.\' name=\'574c368d-deba-4f74-b35a-e7dc5834f372_FormField12_32358840-34c2-4ff4-aadd-7a0b37933eb6_checkbox_12\' id=\'FormField12_32358840-34c2-4ff4-aadd-7a0b37933eb6_1\' class=\'fo-right-margin-5\' data-export-label=\'How_would_you_prefer_to_be_contacted\' ><label for=\'FormField12_32358840-34c2-4ff4-aadd-7a0b37933eb6_1\'>Email</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Phone\' required data-msg-required=\'How would you prefer to be contacted? is required.\' name=\'574c368d-deba-4f74-b35a-e7dc5834f372_FormField12_32358840-34c2-4ff4-aadd-7a0b37933eb6_checkbox_12\' id=\'FormField12_32358840-34c2-4ff4-aadd-7a0b37933eb6_2\' class=\'fo-right-margin-5\' data-export-label=\'How_would_you_prefer_to_be_contacted\' ><label for=\'FormField12_32358840-34c2-4ff4-aadd-7a0b37933eb6_2\'>Phone</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField13_32358840-34c2-4ff4-aadd-7a0b37933eb6\' class=\'control-label  \'>How did you hear about us?</label><div><select  name=\'FormField13_32358840-34c2-4ff4-aadd-7a0b37933eb6\' id=\'FormField13_32358840-34c2-4ff4-aadd-7a0b37933eb6\' class=\'form-control \' style=\'width: auto\'  data-export-label=\'How_did_you_hear_about_us\' ><option value=\'\' selected>( Please Select )</option><option value=\'Google Search\'>Google Search</option><option value=\'Silver Cross Hospital website\'>Silver Cross Hospital website</option><option value=\'Television\'>Television</option><option value=\'Newspaper\'>Newspaper</option><option value=\'Radio\'>Radio</option><option value=\'Direct mailer/flyer\'>Direct mailer/flyer</option><option value=\'Physician, provider\'>Physician, provider</option><option value=\'Nurse\'>Nurse</option><option value=\'Friend/family\'>Friend/family</option><option value=\'Other\'>Other</option></select></div></div><div class=\'form-group\'><label  class=\'control-label  \'>I would you like to stay connected with Silver Cross on upcoming events, health tips and newsletters.</label><div><div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Yes\'  name=\'574c368d-deba-4f74-b35a-e7dc5834f372_FormField14_32358840-34c2-4ff4-aadd-7a0b37933eb6_checkbox_14\' id=\'FormField14_32358840-34c2-4ff4-aadd-7a0b37933eb6_1\' class=\'fo-right-margin-5\' data-export-label=\'How_would_you_like_to_stay_connected\' ><label for=\'FormField14_32358840-34c2-4ff4-aadd-7a0b37933eb6_1\'>Yes</label></div></div></div></div><div class=\'form-group\'><label for=\'FormField23_32358840-34c2-4ff4-aadd-7a0b37933eb6\' class=\'control-label  \'>Comments:</label><div>\
<textarea rows=\'10\' name=\'FormField23_32358840-34c2-4ff4-aadd-7a0b37933eb6\' id=\'FormField23_32358840-34c2-4ff4-aadd-7a0b37933eb6\' class=\'form-control textarea-medium\'   data-export-label=\'Comments\'  placeholder=\'\'></textarea>\
</div></div><p>By clicking the <strong>Submit&nbsp;</strong>button, you agree to the <a href=\'https://www.silvercross.org/privacy/\'>Silver Cross Hospital Privacy and Disclaimer.</a></p>\
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