Survey - Lung Cancer Surgery - Brochure Request Form

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Lung Cancer Surgery - Brochure Request Form

The Lung Cancer Surgery brochure, produced by the American Lung Association, is available in one size (8.5" x 11" bifold). There is a limit of 500 copies per facility. Requests will be considered on a first come, first served basis. Deadline is December 15, 2022. The requested number of brochures will be shipped directly to the address provided at no cost.
All questions may be sent to Taimoor.Zahir@lung.org.

Who is the main point of contact for this request? Please provide their contact information.


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Phone Number: Required
	If you respond and have not already registered, you will receive periodic updates and communications from American Lung Association.

What is the shipping address for the requested amount of printed brochures?


*	First Name: Required
*	Last Name: Required
*	Address Line 1: Required
*	Address Line 2 (Optional): Required
*	City: Required
*	State: Required
*	Zip Code: Required

Question - Not Required - What is the name of the facility that will be utilizing these printed brochures?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - Will the requested brochures be used for patients that are eligible for a Low dose CT Scan?

Question - Not Required - Other

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - How many printed brochure copies would you like to request? (Maximum: 500)