FOBT Test Request Form

Australian medical guidelines recommend FOBT screening every 2 years for EVERYONE aged between 45-74.

A free test kit is available every 2 years for all Australians who are aged between 45-74, have a Medicare Card and entitlement type of either Australian citizen, permanent migrant or registered DVA customer, and have an Australian mailing address.

On completion of this form, Positive FOBT will check your eligibility and if suitable, will send an FOBT kit to you.

Remember, early detection saves lives!!

Patient Details

Patient First Name *

Patient Last Name *

Gender (as registered with Medicare) *

Male FemaleIndeterminate/Intersex/Unspecified

Date of Birth *

Mobile Phone No. *

Email Address

Address *

Suburb *

Postcode *

Medicare Number *

Medicare Ref. No. *

DVA Card (if applicable)

I consent for my personal details to be collected in the above form, and agree to the Terms & Conditions and Privacy Policy of this website. I understand that my details will be submitted to the National Bowel Cancer Screening Program to check my eligibility and to organise for my test kit to be sent out. My details will not be used for any other purposes. *

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