Outpatient appointment form

Please note, for imaging, sexual health, HIV and breast care appointments you should contact the services directly.

About you
First name*
Last name*
Date of birth*
NHS number
Trust ID number

Your NHS number and the Trust ID number can be found on your appointment letter.
Your appointment
If your department does not appear here, please call switchboard on 01273 696955.
Department*
Hospital site*
Date of appointment*
Time of appointment (24 hour clock)

: Hours

Minutes

Enter your appointment time as stated on your letter.
What would you like to do?
I want to:*
- 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.
- CANCEL – I no longer need this appointment.
Phone number and/or email (best contact)*
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
Privacy policy
I agree to the privacy policy.
I can confirm that I have read, understood and accept the privacy policy.