Cervical 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 Cervical 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 * Defer Screening Opt Out Cease Contact and Correspondence Nominate Healthcare Provider Nominate Pseudonym

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.

For participants