Dynamis

Smear Self Referral Page 1 of 1 Please check questions marked in red...
Title
First name
Last name
Date of birth
NHS number if known
House/ Flat number
First Line of Address
Second Line of Address
Postcode
Mobile Number
Email Address
Which GP are you registered at?
Any Disabilities we need to be aware of?
Which Appointment do you require?
Are you due a smear?
Have you had a letter in the post inviting you to attend for a cervical smear?
When was your last smear? If unsure leave blank
What was the result of your last smear?
Have you had any of the following occur in the last 12 weeks? IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE, YOU WILL NEED TO WAIT 12 WEEKS FROM THE EVENT BEFORE A SMEAR CAN BE TAKEN	Miscarriage Termination of pregnancy Insertion of coil Removal of cervical polyp or any procedure where the cells on the cervix have been disturbed Given birth Inadequate cervical screen result
Where did you hear about our service?