Support to screening referral form – Cervical/HPV Screening - Waitaha Primary Health

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Support to screening referral form – Cervical/HPV Screening

Overview
Cervical cancer is one of the most preventable cancers. Early detection of persistent HPV infections through HPV Primary Screening, in addition to HPV vaccination efforts, is intended to help the country meet its goal of eliminating cervical cancer.

When practices have attempted all recalls and still have not been able to screen priority group women who are overdue for screening they can refer to this free service.

The purpose of this service is to provide targeted follow-up, community outreach and support to priority group women who have barriers to accessing screening.

This is a referral service ONLY. It is not a claimable service.

Please complete the referral form below

Support to screening referral form – Cervical/HPV Screening

Priority group patient details

Patient name and personal details

Name(Required)

First Last

NHI

Home phone number

Cell phone number(Required)

Email

Please advise how many attempts have been made to contact the patient

Patient eligibility information

1. Please tick which group the patient belongs to (Maori, Pacific women 25-69 years. Any other women 30–69 years)

isMaori

Maori

isPacific

Pacific Island

isOtherEthnicity

Other (please state)

Other Ethnicity

2. Please tick which statement is correct:

isUnscreened

Patient has never had a cervical smear (unscreened)

or

isOverdue

Patient has not had a cervical smear in the previous five years (significantly overdue)

Date of last smear:

Result of last smear

Smear history if available

Other health considerations that we can support, connecting the patient back into Primary Care

Comments/Useful information

Referrer and GP practice contact information

Referrers Name(Required)

Referrers Role

GP practice(Required)

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