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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.

Note: Fields marked with an asterisk (*) are mandatory.

Are you completing this form for yourself? *

Your details:

Participant details:

Patient details:

The number displayed at the upper right of your bowel screening letter or lower left of your cervical screening letter

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

We require an email address so we can contact you if there are any issues processing your request. If you prefer not to share your email or do not have one, please call our Contact Centre at 1800 627 701.

If you would like the participant to be contacted if there are any issues processing this request, please provide their email address.

If you would like your patient to be contacted if there are any issues processing this request, please provide their email address.

Authorised personal representative details:

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.

We require an email address so we can contact you if there are any issues processing your request.

Healthcare provider details:

If you are filling in this form as a healthcare provider on behalf of a patient, please provide your name and contact information.

We require an email address so we can contact you if there are any issues processing your request.

Any personal information provided to the NCSR, including your email address, will only be used to assist in processing this request.

For more information on how personal information is handled, view the privacy policy and frequently asked questions.

  • 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 NCSP addressed to my preferred name.
  • I may update my preferred name 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 Withdraw Previous Request form for the cervical program, or by calling the Contact Centre on 1800 627 701.
  • I declare that I am the screening participant and submitting this form on my own behalf.
  • I acknowledge that the screening participant I am submitting this form on behalf of (including myself as their personal representative) will receive correspondence sent from the NCSR for the NCSP addressed to their preferred name.
  • They may update their preferred name 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.
  • They may also withdraw this request at any time by completing a Withdraw Previous Request form for the cervical program, or by calling the Contact Centre on 1800 627 701.
  • I declare that I am the screening participant's authorised personal representative and have their consent to submit this form.
  • I acknowledge that the patient I am submitting this form on behalf of (including their healthcare provider) will receive correspondence sent from the NCSR for the NCSP addressed to their preferred name.
  • The patient may update their preferred name 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.
  • The patient may also withdraw this request at any time by completing a Withdraw Previous Request form for the cervical program, or by calling the Contact Centre on 1800 627 701.
  • I declare that I am the patient's healthcare provider and have their consent to submit this form.
Acceptance of terms *