Bowel Screening - Request to Nominate a Healthcare Provider

Use this form to choose a/my preferred doctor to receive notifications from the National Cancer Screening Register for the National Bowel Cancer Screening Program.

Participant

Healthcare Provider

Personal representative

If signing on behalf of the participant, please provide your name and contact information.

Please note: to fill in this form as an authorised representative, your details must exist within the Register as a personal representative. If you are not personal representative within the Register, we will not be able to process your request.

If you are unsure, please call our Contact Centre on 1800 627 701 before filling in this form.

View the privacy policy

  • I acknowledge that my nominated healthcare provider will be recorded on the National Cancer Screening Register (NCSR) and will be able to access details about me and be contacted if I need to be followed-up in relation to my bowel screening. If I see another healthcare provider for bowel screening, they will also be recorded in the NCSR and will receive information about my bowel screening.
  • I may withdraw my request at any time by completing a withdraw request form, or by calling the contact centre on 1800 627 701.
  • I declare that I am the participant or their authorised personal representative.
  • I acknowledge that my selected request(s) will be actioned.
Acceptance of terms *