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Cancel or change your outpatient clinic appointment

Please be aware that if you cancel your appointment twice, we may discharge you back to your GP.

If you have a general query regarding your appointment or you need to cancel / change your appointment as a matter of urgency, it is recommended that you phone the relevant department to speak to them directly. 

The department telephone number will be located on your appointment letter or appointment card. 

Do not submit this form if:  

  1. Your appointment was booked electronically through the NHS e-Referral Service (instead call e-Referral Service Appointments Line on 0345 60 88 88 8. Opening hours are: Weekdays 8am to 8pm; Weekend and Bank holidays 8am to 4pm (closed on Christmas Day). Or you can cancel online through e-Referral Service if you have your Booking reference and Password, provided by your GP)
  2. Your appointment is within the NEXT 48 HOURS 
  3. You have an appointment for an X-ray, CT, MRI or Ultrasound 
  4. You have an appointment in Maternity or Obstetric Outpatient or Ultrasound 
  5. You have a Palliative Medicine or Chemotherapy appointment 


If your appointment applies to options 2 to 5 above you must contact the relevant department directly. 

For your information: 

  • This form is for Derby Hospital Outpatient appointments ONLY 
  • You can submit this form for your own appointment OR on behalf of someone else (e.g. a child or next of kin, carer or advocate) 
  • All the information you need to complete this form is available on your appointment card or letter 
  • If you wish to cancel more than one appointment on the same day you will need to submit a separate form per appointment.


» Indicates required fields

Contact us
About the person who has the appointment
(Please write name in full and avoid using initials)
About the appointment
I wish to... »
The information requested in this section can be found on your appointment letter.

Please note: If you select ‘CANCEL my appointment completely’, we will not attempt to re-arrange your appointment. You will NOT be contacted to confirm this cancellation.

If your appointment is in within the next 48 HOURS you must contact the department directly
Please see top of form for departments you CANNOT submit this form for. If you submit this form for any the listed departments it will NOT be processed. Please speak to these departments directly regarding your appointment.
Contacting you
I prefer to be contacted: »
Please confirm the statements below:
My appointment »
Hospital transport »

This form sends information to a Derby Teaching Hospitals email address. We always treat your information with the strictest confidence and will not pass any information to third parties. Derby Teaching Hospitals 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.