Cervical Screening - Request to Defer My Next Screening Date

Use this form to delay a future screening date and reminders for a period of time being sent from the National Screening Register for the National Cervical Screening Program.

Medicare or Department of Veterans Affairs Number *

Given Name(s) *

Family Name *

Date of Birth *

Postal Address *

Suburb *

State *

Postcode *

Phone

Reason to Defer Screening * Medical advice to defer Living or Travelling Overseas Other

Reason *

Defer until date *

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I acknowledge that I can still screen at any time and the results will be recorded on the National Cancer Screening Register and can be viewed by my healthcare providers.
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 * I have read, understood and agree to these statements. *

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Cervical Screening - Request to Defer My Next Screening Date

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