Bowel Screening - Request to Defer My Next Screening Date

Use this form to delay a future screening date and reminders for a period of time being sent from the National Cancer Screening Register (NCSR) for the National Bowel Cancer Screening Program (NBCSP).

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

Are you completing this form for yourself? * Yes No – as a healthcare provider on behalf of a patient No – as an authorised personal representative on behalf of someone else

Medicare, NCSR ID, or Department of Veterans' Affairs (DVA) number *

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

Date of birth *

Postal address *

Suburb *

State *

Postcode *

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.

Email address *

Phone number

Reason for deferring your next screening date * Medical advice to defer Recent bowel cancer screening Recent colonoscopy Illness Living or Travelling Overseas Other (please specify)

Please describe your reason for deferring your next screening date

Defer until date *

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.

Given name(s) *

Family name *

Date of birth *

Postal address *

Suburb *

State *

Postcode *

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

Email address *

Phone number

What is your relationship to the participant *

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 can still screen at any time and the results will be recorded on the NCSR and can be viewed by my healthcare providers.
I may withdraw my request at any time by completing a Withdraw Previous Request form for the bowel 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.

Acceptance of terms * I have read, understood and agree to these statements

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Bowel Screening - Request to Defer My Next Screening Date

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