Cervical Screening - Request to Nominate a Healthcare Provider

Use this form to choose a/my preferred doctor to receive notifications from the National Cancer Screening Register for the National Cervical Screening Program.

Healthcare Provider

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.

  • I acknowledge that my nominated healthcare provider will be recorded on the National Cancer Screening Register (NCSR) and will be able to access details about me and be contacted if I need to be followed-up in relation to my cervical screening. If I see another healthcare provider for cervical screening, they will also be recorded in the NCSR and will receive information about my cervical screening.
  • 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 *