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 participants invited for cervical screening, you need to sign and return this form to confirm that you do not wish to receive any future invitations from 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.

Participant Date of Birth
Participant Address

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