Date of Smear LMP Parity: Please Tick
Hormones/HRT IUCD Pregnant
LABORATORY USE ONLY WOMAN’S DETAILS DOCTOR / SMEARTAKER Management Recommended 1 Path Date Reported Signature Personal Public Service Number CSP ID Date of Birth Surname First Name Middle Name Surname at Birth Mother’s Maiden Name Postal Address for Correspondence Contact Telephone No. Day Numbers Letters Month Year Day Month Year Day Month Year Day Date Received in Laboratory Accession Specimen Number: Barcode TZ Cells Yes No Final Report Day Month Year Woman’s Signature: CS/F/PM-7 Rev 5 Lab Name Lab No. Test Date Result Smeartaker ID: Telephone No.: Smeartaker Name: Address: Previous Smear History Previous Treatment History INCOMPLETE FORMS MAY BE RETURNED Cervical Cytology Form I consent to take part in CervicalCheck Relevant Clinical Findings Relevant Clinical Details: (derived from Medical Council or An Bord Altranais No.) Clinically Responsible Doctor ID (derived from IMC No.) PCRS / GMS No. Information Information Sheet for Women Freephone 1 800 45 45 55 Information about smear tests and results A What is a cervical smear test? A cervical smear test (also known as a pap test) is a simple procedure where a doctor or nurse (smeartaker) takes a sample of cells to look for early changes in the cells of the cervix (the neck of the womb). If these are not found and treated, they could become cancer cells. The earlier cell changes are found, the easier they are to treat. B Limitations of a cervical smear test As with all screening tests, cervical screening may not always be 100% accurate. There is a small risk that cell changes will not be picked up in a cervical smear test. However, any cell changes will usually be picked up on future smears. This is why it is important to have regular smear tests. C How do I get my result? CervicalCheck will send you a letter about your results within four weeks of having your smear test. The result of your test is also available from your smeartaker. D I'm afraid of what the result might mean… Most smear tests are normal. Even a result that is not normal is unlikely to mean you have cancer. It may be due to minor cell changes. Please try not to worry if you are called back for another test. Consent to take part in CervicalCheck 1 Why are you signing this form? To allow CervicalCheck to receive, hold and use your personal details and information about your smear test sample. This may include past smear tests and colposcopy results. CervicalCheck may share this information with the doctor or nurse who took your smear test (smeartaker), laboratory staff, colposcopy clinic, the National Cancer Registry and their servants or agents. 2 What is the Cervical Screening Register? The Register is a secure electronic database which contains your name, address, date of birth and Personal Public Service Number (PPS No.). Be assured that your information is secure. To maintain confidentiality, each woman has a unique identification number on the Register, known as the Cervical Screening Programme ID (CSP ID). The Register also records the results of your cervical smear tests and any related procedures that you might have had. 3 How will my information / smear test sample be used? CervicalCheck uses the information on the Register to invite you for your free smear test. CervicalCheck, your smeartaker, laboratory or colposcopy clinic may use the information on the Register to advise you if any follow-up treatment is needed and when to have your next smear test. CervicalCheck will include your information in statistics and reports. This will help to review CervicalCheck and find out how well it is working. We may use the Register to invite you to take part in research. Your smear test sample and details may be used for research, teaching and review (audit) purposes. CS/F/PM-7 Rev. 5
userfiles/CHESS KONKURS KOHKYPC(1).doc
Post Menopausal Post Colposcopy Smear Cervix Visualised