Volunteer Doctor Participation & Media Consent Form

Thank you for volunteering your time and expertise. Please complete the form below. Once signed, a protected download link and password will be emailed to you, with a copy sent to the 4FR Health team.

Secure SharePoint storageDigital signatureProtected PDF copy

Questions before completing the form?Read the Volunteer Doctor Frequently Asked Questions for practical information about the campaign, sessions and clinical workflow.

Read the FAQs PDF

Leave this blank

01

Volunteer Information

Tell us who you are and how we may contact you.

Full name *

Practice name *

HPCSA registration number *

Email address *

Cell number *

02

Volunteer Session(s)

Add all dates and time slots allocated to you.

Date(s) *

Time slot(s) *

03

Social Media & Practice Information

Provide the details you would like us to use when acknowledging your participation.

Preferred name for marketing or social media

Practice name, if different

Practice address Optional

Practice website Optional

Facebook Optional

Instagram Optional

Other social profile Optional

04

Photo Consent

Please indicate your preference.

Use a public professional photographI consent to 4FR Health and #Pads4Paps using a publicly available professional photograph of me for campaign marketing. I will provide a professional photographI may upload the photograph below now, or provide it separately to the campaign team. Do not use my imageI do not wish my image to be used.

Professional photograph Optional JPG or PNG, maximum 8 MB. This will be stored with your signed form.

05

Volunteer Declaration

Please confirm each statement before signing.

I am voluntarily participating in the #Pads4Paps campaign. I understand that my participation is entirely voluntary and that I will receive no remuneration, compensation, or reimbursement for my services. I understand that I may withdraw my participation by providing reasonable notice to the campaign organisers should unforeseen circumstances arise. I consent to providing women’s health consultations and cervical cancer screening, including Pap smear consultations, during my allocated volunteer session(s) as part of the campaign. I consent to 4FR Health and #Pads4Paps using my name, practice details, professional profile and, where applicable, my approved photograph for promotional material relating to my participation in the campaign, including the website, social media platforms, newsletters and other campaign communications. I understand that any photographs or promotional material will be used solely for the purposes of promoting the #Pads4Paps campaign and related awareness initiatives.

06

Signature

I have read and understood the above and agree to participate in the #Pads4Paps campaign on the terms outlined above.

Doctor’s name *

Date *

Digital signature *

Sign inside the box
Use your finger, stylus, or mouse

Upload signature

A signature is required before submission.

I confirm that the information supplied is accurate and that this electronic signature represents my agreement.

Your signed PDF will be securely uploaded to SharePoint. A protected access link and separate password will be emailed to the address above.

#Pads4Paps 2026Women helping women