First Name
Last Name
Email Address
Mailing Address
City Select Anmore Belcarra Bowser Coombs Coquitlam D'Arcy Earls Cove Egmont Errington Gambier Island Gambier Harbour Garden Bay Gibsons Granthams Landing Halfmoon Bay Langdale Lasqueti Lighthouse Country Madeira Park Mount Currie Nanoose Bay New Westminster Parksville Pemberton Pender Harbour Port Alberni Port Coquitlam Port Mellon Port Moody Qualilcum Beach Roberts Creek Savary Island Sechelt
Postal Code
Telephone Number
Birthdate Eligible age for screening is 25-69
Primary Care Provider

If you do not have a primary care provider leave blank or type none. If follow-up is needed after screening you will be linked to a clinic in a pilot community.

Cervix Self-Screening is not recommended for people who are pregnant, have had a total hysterectomy, have had a solid organ transplant or who are HIV positive. Please speak with a health care provider about your screening options.

Please note information in this form may be routed outside of Canada in transit as metadata. Formspree utilizes AWS cloud platform which may be subject to laws that may compel it to disclose your personal information without notifying PHSA. In accordance with FIPPA s. 33(2)(v)(i), PHSA completed an assessment to ensure that safeguards are in place to secure your personal information. If you have any questions about the collection and use of your personal information, please contact screening@bccancer.bc.ca. For more information about privacy please visit www.screeningbc.ca