About you

First name (required) ^*

Last name (required) ^*

Date of birth (required) ^*

Day

Month

Year

NHS Number

Patient Reference Number

Your NHS number and Patient Reference number can be found on your appointment letter.

Your appointment

Department (required) ^*

Department name (if not listed above)

Hospital site (required) ^*

Date of appointment (required) ^*

Time of appointment (24 hour clock) ^*

Enter your appointment time as stated on your letter.

What would you like to do?

I want to: (required) ^*

CANCEL - I no longer need this appointment.

RESCHEDULE - I would like to move this appointment. If this is the 2nd time you are rescheduling you may be discharged back to your GP.

If rescheduling please state why and when may be a more convenient appointment date:

If necessary we will contact you between 9.00am - 5.00pm, Monday to Friday

If you have selected to CANCEL this appointment and you will not be offered another appointment and discharged from our services. Are you Sure?

Yes No

Please state the reason for your request

Phone number and/or email (best contact) (required) ^*

Privacy policy

I agree to the privacy policy

I can confirm that I have read, understood and accept the privacy policy privacy policy