Smear Cessation Form

 

 

Cervical screening is very important in preventing cancer.

Please see https://www.gov.uk/government/publications/cervical-screening-description-in-brief

If you really don’t want it please download the smear cessation form, fill It and return it to us.

smear cessation

 

Informed​​ consent​​ for​​ withdrawal​​ from​​ the​​ Cervical​​ Screening​​ Programme

 

This form should be used only if you wish to permanently withdraw from the NHS Cervical Screening Programme.

 

To​​ remove​​ your​​ name​​ from​​ the​​ list​​ of​​ women​​ invited​​ for​​ cervical​​ screening,​​ you​​ need​​ to​​ sign​​ and​​ return​​ this​​ form​​ to​​ confirm that​​ you​​ do not wish​​ to​​ receive any future invitations or any further information about the​​ NHS​​ Cervical Screening​​ Programme.

 

If​​ you​​ wish​​ only​​ to​​ delay​​ your​​ next​​ cervical​​ screening​​ test,​​ then​​ do​​ NOT​​ use​​ this​​ form.​​ You​​ can​​ delay​​ your​​ next​​ test​​ by contacting​​ your​​ General​​ Practitioner​​ (GP)​​ who​​ will​​ be​​ able​​ to​​ advise​​ you.

 

Please​​ read​​ the​​ leaflet​​ ‘NHS​​ cervical​​ screening:​​ helping​​ you​​ decide’​​ that​​ explains​​ the​​ benefits​​ and​​ disadvantages​​ of cervical​​ screening​​ and​​ the​​ importance​​ of​​ screening​​ in​​ reducing​​ deaths​​ from​​ cervical​​ cancer.​​ The​​ risk​​ of​​ developing cervical​​ cancer​​ can​​ be​​ significantly​​ reduced​​ by​​ having​​ regular​​ screening.​​ If​​ you​​ need​​ further​​ information,​​ please​​ do​​ not hesitate​​ to​​ contact​​ your​​ GP.

 

CSAS​​ will​​ send​​ you​​ written​​ confirmation​​ when​​ your​​ name​​ has​​ been​​ removed​​ from​​ the​​ screening​​ list.​​ If​​ you​​ change your​​ mind​​ after​​ you​​ have​​ sent​​ this​​ form​​ to​​ the NHS Cervical Screening Administration Service (CSAS),​​ please​​ contact​​ your​​ GP​​ who​​ can​​ ask​​ for​​ your​​ name​​ to​​ be​​ put​​ back​​ on​​ the​​ screening​​ list.

 

Declaration

Please do not send me any further invitations to participate in the NHS Cervical Screening Programme. I assume full responsibility for this decision and confirm that I have understood the leaflet on cervical screening which explains the benefits and disadvantages of cervical screening and the importance of screening in preventing cervical cancer and reducing deaths from it.

 

I understand that my name can be restored to the screening list at any time at my request to my General Practitioner

 

SIGNATURE:

 

NAME (PRINTED):

 

Date

NHS NUMBER:​​ 

 

DATE OF BIRTH:​​ 

 

ADDRESS:​​ 

 

POSTCODE:

  ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​​​ 

 

Next Steps

We recommend you keep a copy of this form (e.g. photocopy or photograph).

 

Please give this form to your GP who will keep a copy in your medical record and send a copy to us.

 

If you have not received written confirmation that we have received your form within 2 weeks, then please contact your GP.

 

Next steps for Practices: Once completed and signed, please upload this FORM via the​​ CSAS​​ website. You should use the online enquiry form on the ‘Contact Us’ page and select the ‘Cease’ option. Keep the original copy in your files.

 

Comments are closed.