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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

Contact us

About the person who has the appointment                                                    


About the appointment

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

Contacting you

Text message reminder
I prefer to be contacted: »

Please confirm the statements below:

My appointment »
Hospital transport »

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.