Support to screening referral form – Cervical/HPV Screening

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


Patient eligibility information

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


2. Please tick which statement is correct:


Referrer and GP practice contact information