Cervical Screening Appointment Request

Cervical Screening Appointment Request

Please fill in this form if you would like an appointment a cervical screening appointment (smear test). A member of the reception team will be in touch.
People with a cervix aged 25–49 are screened every 3 years. Those aged 50–64 years are screened every 5 years. Please do not request a test before it is due, because the laboratory will reject the sample.
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number
Please read the information in this link:

https://www.nhs.uk/conditions/cervical-screening/
Preferred days of the week

MondayTuesdayWednesdayThursdayFriday
Preferred times

MorningAfternoon
Special requirements or requests (eg hearing / vision / mobility problems, specific dates)
Should be Empty: