Cervical Screening - Request to Opt Out

Use this form to opt out of all participation in the National Cancer Screening Register (NCSR) for the National Cervical Screening Program (NCSP).

Before filling in this form, please read important information about opting out of the NCSR.

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

Provide 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.

Reason for opting out *
Confirmation

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.

Please ensure the address matches the one registered against your medical ID number

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 will not be contacted or be sent any further correspondence from the NCSR for the NCSP. I can still undergo a cervical screening test at any time through a healthcare provider.
  • No further cervical screening information about me will be recorded on the NCSR. My healthcare providers can be informed that I have opted out but will not be able to access my screening details.
  • I may withdraw my request at any time by completing a Resume Participation 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 will not be contacted or sent any further correspondence from the NCSR for the NCSP. The participant can still undergo a cervical screening test at any time through a healthcare provider.
  • No further cervical screening information about the participant will be recorded on the NCSR. The participant’s healthcare providers will see that they have opted out but will not be able to access their screening details.
  • I, the participant, or their healthcare provider may withdraw this request at any time by completing a Resume Participation 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 will not be contacted or sent any further correspondence from the NCSR for the NCSP. The patient can still undergo a cervical screening test at any time.
  • No further cervical screening information about them will be recorded on the NCSR. The patient's healthcare providers will see that they have opted out but will not be able to access the patient's screening details.
  • I, the patient, or their personal representative may withdraw this request at any time by completing a Resume Participation 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 *