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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?

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Date of birth

*This is a mandatory field. Hospital number

Clinic or clinician name, if known

*This is a mandatory field. Speciality

*This is a mandatory field. Your appointment date

*This is a mandatory field. You are cancelling this appointment. Would you like to book another appointment?

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No

*This is a mandatory field. Why are you cancelling your appointment?

If you selected other, please tell us why

Are there any dates that you are not available in the next three to four months?

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