Outpatients appointment cancellation and rescheduling form for Weston General Hospital

Please complete all of the fields below to change or cancel your appointment

Are you the patient?

YesNo (relative)No (carer)No (healthcare professional)No (other)

Patient's full name

Which speciality is you appointment with? (If your speciality isn't listed here, please call the switchboard on 01934 636363).

ColorectalGeneral Surgery/Upper GastrointestinalOrthopaedicsCardiologyRespiratory Haematology/LipidMovementCare of the ElderlyDiabetes/EndocrineENTGastroenterologyOphthalmologyRheumatology

What would you like to do?

I would like to change the date of my appointmentI wish to cancel my appointment

Reason for change

IllnessWork commitmentsOn holidayMore pressing engagementClashes with another appointmentOther

Hospital or NHS number

Date of appointment

Patient's date of birth

Patient's address (including post code)

Contact telephone number (in case we need to phone you back)

Patient's email address

Your name, if different to the patient (if you are the patient please put N/A) 

Your telephone number, if different to the patient (if you are the patient please put N/A)

Any further comments or questions?

NoYes

If Yes (please specify)

I consent to having my information stored for the purpose of this online outpatient amendment/cancellation form. I know you may need to contact me with information in relation to my form. I understand that if I don't consent I cannot submit online.