Cervical Screening Request

Please complete this form if you have been invited for a cervical screening test (smear test) by the surgery, and you want us to contact you to book an appointment or decline the offer.

We hope that this form will be more convenient for you than calling the surgery.

Cervical Screening Request

If you are human, leave this field blank.

Cervical Screening helps prevent cervical cancer by checking for a virus called HPV (human papillomavirus) which can cause abnormal changes to cells in your cervix.

If you are 25-49 years old you will be invited every 3 years. If you are 49-64 years old you will be invited every 5 years.

Every year over 3,000 women in the UK are diagnosed with Cervical Cancer. 2 women die from Cervical Cancer every day in the UK. 99.8% of cases could have been prevented by having a cervical screening test. This test can help to save lives.

You can find more information regarding NHS cervical screening on the NHS website: www.nhs.uk/conditions/cervical-screening

Please let us know whether you like to have a smear, ask for more information or decline the offer: *

I would like to be contacted to book my appointment for a cervical screening test (the surgery will call you)

I would like more information about cervical screening that I have been invited for (the surgery will call you to answer any questions you may have)

I would like to decline the cervical screening invite. I understand the risks of not having cervical screening (please note you may still be contacted in case you change your mind)

Do you have a specific date, day of the week or time of day that would prefer for an appointment?

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Cervical Screening Request

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