Bowel Screening - Request to Withdraw a Previous Request

Use this form to withdraw a previous request made to the National Cancer Screening Register for the National Bowel Cancer Screening Program.

Medicare or Department of Veterans Affairs Number *

Given Name(s) *

Family Name *

Date of Birth *

Postal Address *

Suburb *

State *

Postcode *

Phone

Select the request(s) to withdraw * Request for Replacement Home Test Kit Request to Defer Next Screening Date Request to Opt Out Request to Nominate a Healthcare Provider Request to Nominate a Pseudonym

Personal representative I am completing this form on behalf of a participant

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.

Given Name(s) *

Family Name *

Date of Birth *

Postal Address *

Suburb *

State *

Postcode *

Phone

What is your relationship to the participant *

Relationship *

View the privacy policy

I acknowledge that my selected request(s) will be actioned.
I declare that I am the participant or their authorised personal representative.

Acceptance of terms * I have read, understood and agree to these statements.

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Bowel Screening - Request to Withdraw a Previous Request

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