Cervical smear deferral form Who are you completing this form for? Yourself Someone else For example, on behalf of a child or dependentWhat is the patient’s name? First Last What is the patient's date of birth? Day Month Year For example, 31 3 1980What is the patient's sex? Male Female Other As recorded o their medical recordWhat is the patient's postcode? The one used to register with your GPWhat is your relationship to the patient? Parent Optional Guardian Optional Spouse Optional Carer Optional Son Optional Daughter Optional Sibling Optional Other Optional What is your name? First Last What is your date of birth? Day Month Year For example, 31 3 1980What is your sex? Male Female Other As recorded on your medical recordWhat is your postcode? The one used to register with your GPWhat is your phone number?What is your email address? Anyone else with access to your email account may see responses sent to youNHS Number (if known): Optional Patient's Home Full Address: Street Address Address Line 2 City Postcode Please defer until: Day Month Year Please use date format DD/MM/YYYY (maximum 18 months deferral)Deferral reason: Recent test Currently pregnant Under treatment relevant to screening Under the care of colposcopy Patient’s request to defer If applicable, please provide a copy of your recent test results: Optional Drop files here or Select files Max. file size: 1 GB. Do not upload sensitive photographs of genitalia, bottoms (anus), breasts or minors without asking a healthcare professional first. Your uploads may be stored on your health record.Name OptionalThis field is for validation purposes and should be left unchanged.