Cervical Screening - Resume participation

Use this form to resume participation in the National Cervical Screening Program (NCSP) through the National Cancer Screening Register (NCSR) if you have previously opted out.

If you're not sure whether you are an active participant, please call our Contact Centre on 1800 627 701.

_{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 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

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 will be contacted and receive future correspondence from the NCSR for the NCSP. I will have future cervical screening results from the NCSP recorded on the NCSR. I will be re-invited to screen for cervical cancer by the NCSP. I will be considered a participant in the NCSP. This means my test results will be recorded on the NCSR and correspondence or notifications will be sent to me if necessary.
I may withdraw my request at any time by completing a Request to Opt Out 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.

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

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Cervical Screening - Resume participation

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