Bowel Screening - Request to Nominate a Pseudonym

Use this form to choose a fictitious name to be used on all Register correspondence, notifications and contact in the National Cancer Screening Register for the National Bowel Cancer Screening Program.

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.

  • I acknowledge that I (including my personal representative or nominated healthcare provider, if I have one) will receive correspondence from the National Cancer Screening Register (NCSR) or National Bowel Cancer Screening Program addressed to my pseudonym. My personal information and screening details will be recorded under my pseudonym on the NCSR. My information and screening details will be directed to my pseudonym.
  • 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 *