Tell us if you'd like to cancel or change your appointment
Tell us if you'd like to cancel or change your appointment
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> Tell us if you'd like to cancel or change your appointment
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
*
This is a mandatory field.
Name
*
This is a mandatory field.
Address
*
This is a mandatory field.
Postcode
Telephone number
Do you consent to receiving automated appointment reminders for future appointments?
Yes
No
Date of birth
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*
This is a mandatory field.
Hospital number
Clinic or clinician name, if known
*
This is a mandatory field.
Speciality
Please Select An Option
Cardiology
Ophthalmology
Rheumatology
Orthopaedics - bones/muscles
Surgical
Urology
Neurology
Respiratory Medicine
Gynaecology
Haematology - Clinical
Orthodontics - teeth or dental braces
Ear Nose and Throat
Paediatrics
Nephrology
Neurosurgery
Vascular Surgery
Endocrinology
Gastroenterology
Maxillo-Facial - oral surgery
Clinical Oncology
Neonatology
Breast Surgery
Colposcopy
Pain Management
Dermatology
Nutrition and Dietetics
General Medicine
Diabetic Medicine
Audiology
*
This is a mandatory field.
Your appointment date
DD
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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
Appointment refused
Inconvenient date
Holiday
Sickness
Recovered
Current Inpatient
Seen at another Hospital
Pregnant
Menstruating - Gynaecology appointments
Other
If you selected other, please tell us why
Are there any dates that you are not available in the next three to four months?
Please type the answer to the question in the box
*
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