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Harleston Medical Practice NHS GP Surgery in Harleston

Cervical smear deferral

Cervical Smear Deferral

Required fields are labelled

Who are you completing this form for? Required

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

NHS Number (if known):

Home Full Address:

Please defer until: Required

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

Deferral reason: Required

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:

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.

If you are human, leave this field blank.

Get Help Form Unavailable

This form is currently not available. The form is open between 08:30 and 10:00 Monday to Friday (excluding bank holidays).

If you have an urgent medical problem, that cannot wait until 08:30 the next working day, please contact reception by telephoning 01379 853217 for advice or visit NHS 111 Online.

In an emergency, please call 999.

Bullock Fair Close
Harleston
IP20 9AT

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01379 853217

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