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Cervical smear deferral

Cervical Smear Deferral
Required fields are labelled
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

Please use date format DD/MM/YYYY (maximum 18 months deferral)
Deferral reason: Required
If applicable, please provide a copy of your recent test results:

Do not upload sensitive photographs of genitalia, bottoms (anus), breasts or minors without asking a healthcare professional first. Your uploads may be stored on your health record.