Cervical Screening Deferral Form

Cervical Screening Deferral Form Date: 1 November 2024 Patient Name: Ms. Eleanor Vance Date of Birth: 22/07/1990 NHS Number: 987 654 3210 Reason for Deferral: * Pregnancy (current) * Estimated Due Date: 15/03/2025 Screening History: * Last Smear Date: 10/05/2021 * Result: Normal (HPV Negative) * Next Routine Screening Due: 10/05/2024 Proposed New Screening Date: 15/07/2025 (approximately 12 weeks post-partum) Clinician Details: * Name: Dr. Sarah Jenkins * GMC Number: 1234567 * Practice Name: Willow Creek Surgery * Signature: (Digital Signature of Dr. Sarah Jenkins) Patient Consent: * Patient has been informed of the reason for deferral and the proposed new screening date. * Patient understands the importance of attending the rescheduled appointment. * Patient provided verbal consent for deferral on 1 November 2024. Additional Notes: Patient is primigravida, current gestation 20+2 weeks. Advised on signs of potential complications and when to seek medical attention. Provided with information leaflet on cervical screening during and after pregnancy. Advised to contact the surgery if any concerns arise before the rescheduled appointment.