Making, changing or cancelling your hospital appointment


Cancel an appointment/admission

Patient details
Do you want to cancel an appointment or an admission?
*First name:
*Family name:
*NHS number:
(This can be found on the appointment letter)
*Date of birth:    
*Address:
Email address:
*Daytime contact:
Add / update mobile number:
If you are completing this form for the patient tick this box:
Relationship to the patient:

Appointment/admission details
*Date of current appointment/admission:
<January 2017>
MonTueWedThuFriSatSun
2627282930311
2345678
9101112131415
16171819202122
23242526272829
303112345
*Time: :
Consultant:
Do you have / need any special services booked?:
Patient Transport
Patient Interpreter

Other relevant information

no more than approximately 60 words and
include how you wish to be contacted.


Review & terms and conditions
1. I understand that if you cancel this appointment/admission, I will be taken off the waiting list and no further dates will be offered to me.
     2. I understand that if I later change my mind that I will need to return to my GP for a new referral.

  I have read, and agree to abide by the Guy's and St Thomas' NHS Foundation Trust Terms & Conditions