INSTRUCTIONS
HOW TO SELF COLLECT AN HPV TEST Simply follow the step-by-step instructions below: WHAT DOES THE KIT CONTAIN? • • • •
A swab in a plastic tube A plastic ziplock bag This instruction sheet The request form provided by your health professional • A padded ‘Reply paid’ envelope
265 Faraday PO Box 178 St Carlton South P: 03 9250 Carlton South VIC VIC 3053 0300 F: 03 3053 9349 1949
MEDICARE
Given Names
PATHOLOG
Date of Birth
Previous Surnam e Is the patient Torres Strait of Aboriginal or Islander origin?
)*
)*
*Ref: wiki.cancer
.org.au/aus
tralia/Guid
elines:Cerv
ical_cancer
/Screening
In which country
to My Health
COPY REPORT S
Fax
(Complete Medicare
Appearance
LAB CO PY
where approp
riate
bleeding
No
of cervix
Yes
(specify)
Cervix
Other
partum
(specify)
CST taken by nurse Practitioner requesting No. if not practitioner
Same day colposcopy
Practition e Assignment)
r’s Signat ure
X
Request D ate
Requesting
(Section 20A of the Health Insurance approved pathology practitioner Act 1973). I assign my right to who will render Practition er only (please the requested benefits to the tick). Reason pathology service(s) patient unable to sign.
Date
Date Name DOB
Date
MEDICARE ASSIGNMENT
Practitioner (Provider number, Surname, Initials and
• If possible, avoid taking the sample during your monthly period
• Get into a comfortable position as shown above while holding the swab in your hand
/ / Address)
Patient status or when the at the time of the specimen was service collected
Private patient or approved in a private hospital day hospital Private patient in a recognised hospital A public patient in a recognised hospital Outpatient of a recognised hospital
X
Name
Date
DOB
Name
Yes No
/ /
Date
Date
Name DOB
265 Faraday PO Box 178 St Carlton South VIC 3053 P: 03 9250 Carlton South VIC 3053 0300 F: 03 9349 1949 Your
Patient Surnam e
Patient’s Signature
• Undress from the waist down
(specify)
Normal Abnormal
site
Pregnant/Post Hysterectomy IUCD
By Time:
Bulk Bill
Abnormal
Specimen
born?
(please specify)
TO:
Complete patient name and date of to attachin birth prior g specime PLACE LABEL n. If more than VERTICALLY write patient 3 specimens details on additional specimens
3
was the patient
Does the patient speak a English at home? (If morelanguage other than indicate the than one language one that is , spoken most No, English often) only Yes, other
Record
Name
BIOLOGICAL SUBSTANCES CATEGORY B
Do not send
Urgent Phone Phone/Fax No. Private Schedule Vet Affairs No.
DOB
Emergency Contact Numbers: Business hours: (03) 9250 0300 After hours: 0427 308 373
Clinical Notes
UN3373
Tick only
Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Not Aborigin al or Torres Strait Islander
(indication
POSITION:
• Remove the swab out of its plastic tube, just twist and pull it
DOB
doctor The Royal College Pathologists Accredited pathologis has recommended for of Australasia t on clinical that you use with NPAAC compliance MEDICARE grounds, Standards a Medicare VCS Pathology. You CARD and ISO 15189 are free to rebate will choose your only be payable Given Names if that pathologisown pathology provider. t performs the service. However, if your doctor You should discuss this has specified a particular Gender with your doctor. Date of
NUMBER
4
5
TAKING THE SAMPLE:
TAKING THE SAMPLE (continued):
RETURN TO PLASTIC TUBE:
• Gently spread open the folds of skin at the vaginal opening with your other hand
• Rotate the swab gently for 10-30 seconds
• Place the swab into the plastic tube
• There should be no pain or discomfort
• Tightly screw the cap onto the tube
Patient Ad dress
Tests Reques ted
PAT IE N
Birth
Your Referen ce
T COPY
Privacy Note: administratio The information n of government provided will Health Insurance be used to health programs, assess Act 1973. associated and may be any Medicare benefit with this claim, The information payable for or as authorised may be disclosedused to update enrolment the to the Department by law. records. Its services rendered and collection of Health is authorised to facilitate the proper and Ageing by provisions or to a person of the in the medical practice
Telephone
(Home)
Telephone
(Business)
Requesting Practitioner (Provider number , Surname, Initials and
Address)
Patient status the specimen at the time of the service or was collected when Private
patient in a private hospital Private patient or approved in a recognised day hospital A public patient hospital in a recognised Outpatient hospital of a recognised hospital
Yes No
MEDICARE ASSIGN
(Section 20A MENT of the Health Insurance Act I assign my right to benefits 1973). practitione to the approved r who will pathology render the requested pathology service(s)
Patient’s Signatu
re
X
Date
/ / Path_Pub_3
V9
• Insert the swab into your vagina directed towards your lower back about two inches (5cm), half the length of a finger. This is similar to how you would insert a tampon
* This image is adapted from Garrow SC et al. The diagnosis of chlamydia, gonorrhoea, and trichomonas infections by self-obtained low vaginal swabs in remote northern Australian clinical practice. Sex Transm Infect. 2002 Aug; 78 (4):278-81
• Finish by washing your hands with soap and water
>> Instructions overleaf on how to pack and post the sample...
© VCS Foundation Ltd. 2020
Follow up HPV tests L.B.C only
(indication
VCS PATHOLOGY Reply Paid 178 CARLTON SOUTH VIC 3053
Y REQU EST
Your Referen ce
Tests Reques ted CST
SWAB: CARD NUMBE R
Gender
Co-test
2
Corp-Mkt-Pub-146 V1
Patient Surnam e Patient Address
1
*