Use BLOCK LETTERS or 2026

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The document is a Registration & Consent Form for BreastScreen Victoria, which collects personal information necessary for breast cancer screening and assessment. It outlines the legal protections of personal data, the purpose of data collection, and includes questions regarding personal health history, family medical history, and current health status related to breast cancer. The form requires participants to provide consent for their information to be used in accordance with privacy policies.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal details in BLOCK LETTERS. This includes your family name, given names, and date of birth. Ensure accuracy as this information is crucial for identification.
Proceed to answer the questions regarding your health history. For each question, select 'Yes' or 'No' as applicable. If you answer 'Yes', follow any additional prompts for further details.
Fill in your contact information, including mobile number and email address. Make sure these are current so that BreastScreen Victoria can reach you if necessary.
If applicable, provide details about your doctor(s) and their clinic. This ensures that results can be shared appropriately.
Review all entered information carefully before signing at the bottom of the form to confirm its accuracy.

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