Tell us if you'd like to cancel or change your appointment Fill in the form and we'll be in touch Note: Questions marked by * are mandatory Please refer to the privacy notice on how we use and store your data. *This is a mandatory field. Name *This is a mandatory field. Address *This is a mandatory field. Postcode Telephone number Date of birth DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec *This is a mandatory field. Hospital number Clinic or clinician name, if known *This is a mandatory field. Speciality Please Select An Option CardiologyOphthalmologyRheumatologySurgicalOrthopaedics - bones/musclesUrologyNeurologyRespiratory MedicineGynaecologyHaematology - ClinicalOrthodontics - teeth or dental bracesEar Nose and ThroatPaediatricsNephrologyNeurosurgeryVascular SurgeryEndocrinologyGastroenterologyMaxillo-Facial - oral surgeryClinical OncologyNeonatologyBreast SurgeryColposcopyPain ManagementDermatologyNutrition and DieteticsGeneral MedicineDiabetic MedicineAudiologyRadiologyHepatology *This is a mandatory field. Your appointment date DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec *This is a mandatory field. You are cancelling this appointment. Would you like to book another appointment? Yes No *This is a mandatory field. Why are you cancelling your appointment? Please Select An Option Inconvenient dateHolidaySicknessRecoveredCurrent InpatientSeen at another HospitalPregnantMenstruating - Gynaecology appointmentsOther If you selected other, please tell us why Are there any dates that you are not available in the next three to four months? Is there anything else you would like us to know?
