Cervical Smear Deferral

Are you completing this form on behalf of:

Yourself

Someone else (e.g. a child or dependent)

About you

Your First Name(s): *

First Name(s) as appears on your passport.

Your Last Name: *

Last Name(s) as appears on your passport.

Your Date of Birth: *

Your date of birth is required to verify your identity.

Sex: *

Male

Female

Other

As on your medical record.

Your Phone Number: *

The practice may use this number to contact you about your request.

Your Email: *

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please continue completing the form below

NHS Number (if known):

Home Full Address:

Please defer until: *

Please use date format DD/MM/YYYY (maximum 18 months deferral)

Deferral reason: *

Recent test

Currently pregnant

Under treatment relevant to screening

Under the care of colposcopy

Patient's request to defer

If applicable, please provide a copy of your recent test results:

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