Bowel Screening - Request to Withdraw a Previous Request

Use this form to withdraw a previous request made to 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

Your details:

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

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

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. 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

Select the request(s) you want to withdraw: * Withdraw request for replacement home test kit Withdraw request to defer next screening date Withdraw request to nominate a healthcare provider Withdraw request to nominate a personal representative Withdraw request to nominate a preferred name

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 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

Bowel program

Cervical program

Lung program

About the NCSR

Search

Bowel Screening - Request to Withdraw a Previous Request

Your details:

Participant details:

Patient details:

Authorised personal representative details:

Healthcare provider details:

Important information

Contact Us