Nurse Cervical Screening Provider Certification Form

Please complete this form to apply for Nurse Cervical Screening Provider Certification through Cancer Council Victoria.

Personal information






Employment information





Declaration for VCS Pathology

Please complete if using VCS Pathology at your practice/s:

Do you consent for Cancer Council Victoria (CCV) to forward the information in this form VCS Pathology? VCS Pathology will issue a unique ‘practice number’ via email. This practice number enables you to submit your cervical screens to be processed.


Declaration for Private Pathology

Please complete if not using VCS Pathology at your practice/s:

I agree to record statistics and information in accordance with the CCV Statistical Worksheet (which will be emailed to you and available online).


Declarations



To update your details

To update your details, add practice locations or for more information, please email certification@cancervic.org.au or call 1800 111 255.

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