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Cancel or change your outpatient clinic

You CANNOT use this form if your appointment is:

in the NEXT 48 HOURS

in X-ray, CT, MRI or Ultrasound
for a maternity or obstetric outpatient or ultrasound

Instead, please phone the relevant department directly, the number will be located on your appointment card or letter.

This form is ONLY for hospital outpatient appointments
You can use this form for your own appointment OR on behalf of someone else (e.g. a child or next of kin)
The information you will need is on your appointment card or letter.

If you wish to cancel more than one appointment on the same day then you will need to complete separate forms.

» Indicates required fields

About the person who has the appointment

Patient name »

Date of birth (DD/MM/YYYY) »

If you are completing this form on behalf on somebody else please insert your name here

About the appointment

I wish to... »

CANCEL my appointment completely
REARRANGE my appointment
ENQUIRE about my appointment

Please note: If you select 'cancel my appointment completely' it will not be rearranged. You will NOT be contacted to confirm this cancellation.

Date of appointment »

Time of appointment »

Which department your appointment is at? »

Contacting you

Day time telephone number »

Mobile phone number

Email address

Text message reminder

To cancel your text message reminder please tick this box. (We may still telephone you on this number).

I prefer to be contacted: »

By phone
By post

Please note: we cannot contact you by text message, however we can by fax if this is preferred. Please add your fax number into the 'Additional information' box at the bottom.

If you want to be contacted by phone please tell us which time(s) best suit you?

If you would like to rearrange your appointment, please provide the dates /times you would NOT be able to attend a future appointment?

Please state the reason for your change or cancellation of appointment

If 'other' please give a reason

Please confirm the statements below:

My appointment »

I understand that if you completely cancel this appointment for me and I later change my mind, I will need to return to see my GP for a new referral

Hospital transport »

I understand that I need to cancel or rearrange my own hospital transport and this will not automatically be done for me

Additional information

Disclaimer

This form sends information to a Derby Hospitals email address. We always treat your information with the strictest confidence and will not pass any information to third parties. Derby Hospital’s cannot guarantee 100% security when information is in transit over the world wide web. If you have any concerns regarding the security of the world wide web please call the hospital directly to cancel your appointment. Contact us.

Have you read the disclaimer above?

Enter the characters as they appear.