Cervical Screening – Request to Nominate a Preferred Name

Use this form to nominate a preferred or alternate name (a name that you use regularly, such as a nickname or shortened version of your name) to be held in the National Cancer Screening Register (NCSR) for the National Cervical Screening Program (NCSP).

Once your request has been processed:

  • We will use your preferred name for all letters, notifications and contact made through the NCSR for the NCSP.
  • Your request will not change your name as it is currently recorded with Medicare.
  • Your healthcare provider and pathology laboratories will be able to view both your legal and preferred name when accessing your screening record.
  • If you wish to register for the Participant Portal, you will initially need to use your legal name and proof of identity documents for identity verification purposes as these are required for all registrations.
  • If you update your name or address on the Participant Portal, it will update your preferred name and address.

Provided your given name(s) and family name, as recorded with Medicare:

You can either type your date of birth in (dd/mm/yyyy) or use the date picker

Authorised personal representative

Fill in the form below so we can process your request.

To fill in this form as an authorised personal representative, your details must be registered with the NCSR as the screening participant’s personal representative, otherwise 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.

You can either type your date of birth in (dd/mm/yyyy) or use the date picker

View the privacy policy

  • I acknowledge that I (including my personal representative or nominated healthcare provider, if I have one) will receive correspondence, sent from the NCSR for the National Cervical Screening Program addressed to my preferred name.
  • I may update my preferred name or address at any time by completing a Request to Nominate a Preferred name form, or by updating it on the NCSR Participant Portal, or by calling the Contact Centre on 1800 627 701.
  • I may withdraw my request at any time by completing a Request to Withdraw a Previous Request form for the cervical program, or by calling the Contact Centre on 1800 627 701.
  • I declare that I am the participant or their authorised representative.
  • I acknowledge that my selected request(s) will be actioned.
Acceptance of terms *