Cervical Screening Opt-In Form

Cervical Screening Opt-In Form Date: 01 November 2024 Patient Details: Full Name: Sarah Jane Smith Date of Birth: 15/03/1990 NHS Number: 123 456 7890 Contact Number: 07700 900001 Email Address: sarah.smith@example.com Practice Details: Practice Name: Willow Creek Surgery Practice Code: Y01234 GP Name: Dr. Emily White Consent for Cervical Screening: I, Sarah Jane Smith, understand that I am due or overdue for a cervical screening (smear test). I confirm that I have received and understood information regarding the purpose, benefits, and potential risks of cervical screening. I consent to undergo a cervical screening test at Willow Creek Surgery. Additional Information: I have previously had cervical screening tests. My last screening was approximately 3 years ago. I would prefer to be contacted by SMS for appointment reminders and results. I confirm that my contact details are up-to-date and accurate. Patient Signature: Sarah Smith Date: 01 November 2024 Clinician’s Name (if applicable): Dr. Emily White Clinician's Specialty: General Practitioner