QPC Cervical Screening Refusal Form

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Cervical Screening Refusal Form

Cervical Screening

Patient Name *

Patient Email *

I have been informed by *

Dr. Rajnikant Patel Dr Narendrakumar Patel Dr Nidhi Karavadia Medical Staff

They recommended a cervical screening at least every three years for patients between ages 21 to 64 years old. Cervical screening or PAP smear is designed to determine infection, cell abnormalities and/or cancer cells that may present in the cervix and is used as a screening tool. The goal of cervical screening is early detection of cervical cancer.

I confirm with my signature below that: The physician has discussed the above information with me that I have had the chance to ask questions and that all my questions have been answered to my satisfaction and that I voluntarily refuse further testing in the form of cervical screening.

Today's Date *

Patient Signature *

Witness Signature

QPC Cervical Screening Refusal Form

Cervical Screening Refusal Form

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