Free Preventative Breast Cancer Screening

First Name

Last Name

Date of Birth

Phone Number

Address

Township

Post Code

Have you previously attended an appointment at BreastScreen Victoria? If yes, please provide date of last screen?

Do you have breast implants? As this may affect your eligibility.

Yes

Do you identify as a person with a disability?

Yes

If yes, do you require additional support to attend the appointment?

Which pick up point will you be attending?

The Heart, 11 Milton St, Bannockburn

The Well, 19 Heales St, Smythesdale

Do you require additional support to reach a pick up point?

Yes

Privacy Statement

Golden Plains Shire Council is committed to protecting all personal and sensitive information consistent with the Information Privacy & Health principles set out in the Privacy and Data Protection Act 2014 and the Health Records Act 2001.

You have the right to access your personal information and make any necessary corrections. If you have any queries or wish to gain access to amend your information please contact Golden Plains Shire’s Privacy Officer on (03) 5220 7111 or [email protected].

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