Cervical Screening - Request to Nominate a Pseudonym

Use this form to choose a fictitious name to be used on all register correspondence, notifications and contact in the National Cancer Screening Register for the National Cervical Screening Program.

View the privacy policy

• I acknowledge that I (including my personal representative or nominated healthcare provider, if I have one) will receive correspondence from the National Cancer Screening Register (NCSR) or National Cervical Screening Program addressed to my pseudonym. My personal information and screening details will be recorded under my pseudonym on the NCSR. My information and screening details will be directed to my pseudonym.
• 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.