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
(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
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)
Fax
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
Your 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 or Private patient approved day in a recognised hospital A public patient hospital in a recognised Outpatient hospital of a recognised hospital
Yes No
MEDICARE ASSIGNMENT (Section 20A 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 V2
Patient Surnam e Patient Address
1
INSTRUCTIONS
HOW TO PACK & POST THE SAMPLE Simply follow the step-by-step instructions below:
*Ref:
wiki.
t send
.au/au
strali
a/Guid
to
My He Urge alth nt Reco rd Phon Phon e/Fa e x No Privat . e Fax Vet Af Sc he fairs dule No. Bu COPY lk Bi ll REPO
RTS
MED IC ASSIG ARE NMEN
only
TO:
Requ
Tests
Requ
ested
ss
e
Nam
esting
(Provid
er nu
Prac
mber,
Patie Sign nt’s atur e
ame
DOB
Date
e
AND
ADD
RESS
89
Your
DETA
IEN
Privacy Note: adm Healtinistratio The inform atio associ h Insura n of gov ated nce Act ernme n provid nt with ed this 1973. The health will be claim, pro use or as informatiograms, andd to ass Patie author n ma may ess any y ised the spnt statu by lawbe disclo be used Medicare ecim s at th sed to to upd . ben Private en wa e tim the Dep ate enr efit pay patien e s artme olment able for co Private t in a llecte of the se nt of rec the private patien d Health ords. Its servic rvice A pub t in a es hospita col and or lic pat recogn Ageinglection rendered when l or app ient Outpa ised or to is author and to in a roved hospita tient fac recogn a per ise Yes No day hos of a l son in d by proilitate the ised recogn pital hos the me visions pro ised per hospita pital dical of practicthe l e (Se
MED ICARE ction I assign 20A of the ASSIG practi my right Health Ins NMEN tione uranc T r wh to bene e Ac o will
sted
Refe
YR EQ
renc
e
ame,
and
Addr
ess) Patie or whnt statu s at en
Date Nam
e
fits t rende to the ap 1973). pro r the reque ved patho sted patho logy logy servic e(s)
T C OPY Telep h
one
/ /
the sp the tim Private ecim pat or app en wae rov ient in Private ed day hosa private s pital hospita patien A pub t in a l lic pat recogn ient ised hos Outpat ient of in a recogn pita ised hos l a rec ognised pital hospita l
X
(Hom
Your
Date
/ /
t’s Si
X
NUMB ER
12
Date
.06
of
T
of th colle e service cted Yes No
Gender
F
PATHOLOGY REQUEST Date of Birth
or
hospital
PA
No
CST
Is the patient of Aboriginal or Torres Strait Islander origin?
Follow up HPV tests L.B.C only
Co-test
(indication)*
12.06.1989
Abnormal bleeding
Torres Strait Islander Aboriginal and Torres Strait Islander Not Aboriginal or Torres Strait Islander
In which country was
Fax
Patient Surname
Yes
Normal
(specify)
Patient’s Signature
(specify)
Private patient a private hospital or approved day in hospital Private patient in a recognised hospital A public patient in a recognised hospital Outpatient of a recognised hospital
Date
Accredited for compliance MEDICARE CARD College Pathologists with NPAAC Standards of Australasia Your doctor has recommended and ISO 15189 that you use VCS Pathology. pathologist on clinical You are free to choose grounds, a Medicare your own pathology rebate will only be payable provider. However, if that pathologist performs the service. You should if your doctor has specified a particular Given Names discuss this with your doctor. Gender
Date of Birth
PATIENT COPY
Patient Address
Telephone (Home)
Requesting Practitioner
Yes No
/ /
Date Name DOB
NUMBER
Your Reference
Telephone (Business )
(Provider number, Surname,
Initials and Address)
Privacy Note: The information administration of government provided will be used to assess any Medicare health programs, and Health Insurance Act may be used to update benefit payable for the services rendered enrolment records. Its associated with this 1973. The information may be disclosed and to facilitate the claim, or as authorised collection is authorised proper to the Department of by law. by provisions of the Health and Ageing or to a person in the medical practice
Patient status at the time of the service or when the specimen was collected
Private patient in a private hospital or approved day hospital Private patient in a recognised hospital A public patient in a recognised hospital Outpatient of a recognised hospital
Yes No
MEDICARE ASSIGNMENT
(Section 20A of the Health Insurance Act 1973). I assign my right to benefits to the approved pathology practitioner who will render the requested pathology service(s)
Patient’s Signature
X
X
patholog your ist
)
Patient or when
Name
complian 15189Standard ce s the y provider s service. . Howeve Date You shouldr, if your of discussdoctor
r
Tel e
ph o
ne
(H
Birth
DOB MEDI
CARE CARD
this has with specifie your da doctor. particul
om
Practit ioner
(Provid er t’s
Date
Accredite with own and NPAACd for patholog ISO perform
Gende
CO
Reque sting
Patien
PY e)
Tel e
ph
Your
on
.19
Bu
sin
Re q
ue
/
/
st
PATH
89
Your
OLO
nce us
B
GY
Refere
Previo
REQ
UES
T
Surna
CO
me
PY
Da
status Private or approved at patient the Private specime the A public patient day in a time private hospital n Outpatient patient in of a recognised hospital was the collecte in a of service a recognised recognised hospital d Yes hospitalhospital No
te
Date
/
/
NUMB
ER
ar
Refere nce
e(
ess
)
numbe r, Surnam
Signa
e, Initials
ture
and
/
(specify)
Other
Request Date
/ / Patient status at the or when the specimen time of the service was collected
Initials and Address)
X
Date Name DOB
s
NT
Address
DOB
Royal
Addres s)
Da
Abnormal Cervix
CST taken by nurse Practitioner No. if not requesting practitioner
Practitioner’s Signat ure
X Requesting Practitioner
(Provider number, Surname,
Tests Requested
No
Appearance of cervix
Specimen site
the patient born?
Pregnant/Post partum Does the patient speak a language other than English at home? (If more Hysterectomy than one language, indicate the one that is spoken most often) IUCD No, English only Yes, other Same day colposcopy
(please specify)
By Time: (Complete Medicare Assignment)
Date Name DOB
Name
Name
LAB COPY
Tick only where appropriate
Aboriginal
(indication)*
Record
Bulk Bill
(Section 20A of the Health Insurance Act 1973). I assign approved pathology practitioner my right who will render the requested to benefits to the Practitioner only (please pathology service(s) tick). Reason patient unable to sign.
265 Faraday St Carlton South VIC 3053 PO Box 178 Carlton P: 03 9250 0300 F: 03South VIC 3053 9349 1949 The Royal
X
Date Name
The
Patholog College Pathologists will only y. You of Australasia be are payablefree to if thatchoose
rendered
)
Initials
and
’s re
T IE
the and Its services collection Ageing
Your Reference Previous Surname
Tests Requested
*Ref: wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening
Clinical Notes
Do not send to My Health
Urgent Phone Phone/Fax No. Private Schedule Vet Affairs No.
COPY REPORTS TO:
MEDICARE ASSIGNMENT
Complete patient name and date of birth prior to attaching specimen. PLACE LABEL VERTICALLY Date If more than 3 specimens Name write patient details DOB additional specimens on
e,
Patient Signatu
1949 3053 3053
that ,a you Medicaruse VCS e rebate
Given
benefit enrolment payable t of records.for Health
when Yes
ended grounds
or (Section to is authorised a person and CARE I assign to 20A in by facilitate practitio the provisions my of the ASSIG medical the ner right Health of proper practice who to benefits NMEN the Insurance will render to Act T 1973). the the approved requeste patholog d patholog y y service(s
MEDICARE CARD NUMBER
Given Names
Jane Anna
sign.
South
F: South ist has 03 on recomm 9349 VIC VIC clinical
Date
/ /
te
/
Path_Pub_3
V9
Path_Pub_3 V9
• Store the swab at room temperature until delivery
PACKAGING: • Place the plastic tube into the ziplock bag • Then pack the tube and the request form into the padded reply paid envelope • Seal the envelope firmly
renc
3 73 33 UN
Y 53 OG 30 OL TH 178 H VIC S PAPaid UT VC SO N ply TO Re RL CA
gnat
ure
ICAL OG BIOL
S NCE B TA RY BS SU TEGO CA
IF YOU REQUIRE A
: bers Num 0300 tact 9250 Con (03) 373 cy rs: 308 rgens hou 0427 Eme ines rs: Bus r hou Afte
Date
/ /
COMPLETE FORM AND CHECK LABEL: ub_
• If possible, avoid taking the sample during your monthly period
BER
Refe
Path_P
• Your swab should be posted as soon as possible, preferably within 24 hours of collection
NUM
e) e Telep hone (Bus iness ) Requ estin g Prac titione r (Pro vider num ber, Su rnam e, Initi als an d Ad dress)
Patien
st Da te
day
MEDI
LARB E CO CRORP ECY T
Requ e
er
Initials
hospitalhospital
265 Faraday St Carlton South VIC 3053 PO Box 178 Carlton P: 03 9250 0300 F: South VIC 3053 03 9349 1949
Patient Surname
Smith
Patient Address
Name
DOB
9250 Carlton Your Carlton patholog 0300 doctor
res s
Privacy administra Note: Health associated tion The Insurance of informatio with Actgovernmen Patient this 1973. n provided the claim, t status The health Private specime or informatio will programs, as Private patient at be authorised n was used the A public patient n may and to in time a private collecte Outpatient by be may assess patient in law. disclosed of a recognised be any hospital d the used Medicare in of a recognised a recognised service to to the update hospitalor approved Departmen
UES
ILS A
tition
Surn
00 F: South h VIC 30 Your DOB 03 93 VIC 30 53 patho doctor ha Date 49 19 53 logist s re 49 on cli comm nical ended The that grou Royal Nam yo nds, College a Me u use VC e Pathol dicar S Pa ogists e tho of Aus tralasia Given rebate will logy. You DOB Accre only ar Nam be pa e free to with dited for es yable ch co NP if tha oose yo and ISO AAC Sta mplianc t patho ur ow 1518 ndards e n logist pa 9 MED perfo thology prov rm ICARE ider. Gende s the serv Howe CARD ice. r You ver, if yo shou ld dis ur docto Date r ha cuss s sp of Bi this with ecified rth your a docto particu lar r.
PAT
Reque
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dd
DOB
Date
PAT HO
of Bi rth
6.19
X
(Secti on appro 20A of the ved
DOB
Patie nt A ddre
IRTH
me tA
Tests
Abor na nder Prev igin ious origin l or Torres al Surn ? ame Strait Tick Abor only ical_c iginal Islander ance where r/Scre and Not Abno ening Torres Abor appr rmal iginal opriat St ra bl eeding or To it Isl e ande rres Appe In w Strait r aran hich No ce of Islan coun der cervix try w Yes Does as th th e patie Norm (spec English e patient ify) al nt bo Spec rn? indica at hom speak a imen Abno langu e? (If te th rmal site ag No, e one that more than e other Preg Engl na th (sp is on nt/Pos an ecify e la ish on spoken Cerv ) t part most nguage, (plea ly ix Hyst se spe of By Ti um te erecto Yes, Othe cify) me: othe n) r my r IUCD (spec ify) CST take (Com n by Sam plete Prac e da nurs Med y co Prac e icare requ titioner lposco titio estin N Assig ner’s py g praco. if no nmen Sign t) titio t atur ner e )*
CARD r
X
265 PO Farada P: Box 03 178 y St
t Surna
Date
CARE
Gende
F
LA
BER Patien
s:Cerv
265 Fa PO Bo raday St P: 03 x 178 Ca Carlton 9250 rlton Sout 03
t Su rnam
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12.0
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Is the Torres patien Strait
t of Aborig Birth Do Torres inal IslandAborig not r/Screeni send Urgent Aborig Strait er inal to ng origin Phone My Not or inal Health Aborig and Islande ? Private /Fax In Record No. Phone Vet inal Torres r which Affairs or Tick Torres Strait countr Does COPY Schedu only No. Fax Abnorm English the Strait Islande y was where REPOR patient le indicat Islande r at al Appea the home? speak bleedin appro By TS Bulk patien No, e the r Time: rance TO: one (If a priate English Bill g (please t born? that more languag of specify) cervix only is spokenthan e other (Compl Specim MEDI No one most langua than ete ASSIG CARE Yes, Pregna en site Yes Medica Norma often) ge, other NMEN Compl re (specify) (Section Abnorm l Hyster nt/Pos Assignm and approved 20A ectom t partum to dateete patient T Pra al IUCD of ent) attach Practitiopathologthe cti PLACE Cervix of y Health (specify) tio If ing birth name Same ne ner y practition Insurance writemore LABEL specimprior r’s only day Other than VERTIC additio patient Sig (please er who Act colpos na CST 1973). 3 specim en. tur nal tick). will (specify) details ALLY Practittaken Reque e copy renderI assign specim Date Reason reques ens (Provide the my ioner by sting Name ens on right patientrequested ting No.nurse DOB r number to Practi benefits practit if Date unable patholog , Surnamtioner not to ioner to the y service(s)
Pa ti
eline
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Patien
F
OF B
Is th Torrese patien Strait t of Abo rigi Isla
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s
An
tests
n)*
SU CA BST TE AN GO CE RY S B
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IMPORTANT INFORMATION
Patien
Sm
Patien
Tests Co-test
*Ref:
MED
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ss
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t Add re
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DOB
1
3 V9
• Check that the details on your form and the plastic tube are correct. • Ensure that you sign the form and record the date of collection as marked above. • Your sample does not require refrigeration. Just keep at room temperature
POST: • Deposit the reply paid envelope into an Australia Post mail box preferably within 24 hours of collection
REPLACEMENT KIT, OR FOR MORE INFORMATION CONTACT VCS PATHOLOGY ON PH: 03 9250 0300
• Your sample must be tested within 28 days of collection. >> Instructions overleaf on how to take a vaginal swab - DO THIS FIRST...