This site is best viewed with a modern browser. You appear to be using an old version of Internet Explorer.

Outpatient appointment request form

This form can be used to book, cancel and change outpatient appointments

The Patient Contact Centre aims to process this request within two working days, however if full details are not provided it may take longer.

This form is not suitable for 'on the day' or 'next day' cancellations. To contact us about these, please call:

Patient Contact Centre
Tel: 01865 231405
Monday to Friday 8.00am - 6.00pm

The information you put in this form will be emailed to us.

We treat the information you give us with the strictest confidence, and do not pass any information on to a third party; however, emails are not secure and may be intercepted.

If you are concerned about the security of your information when using this form, please telephone us instead.

Tel: 01865 231405

Fields marked * are required.

Your details

First Name *

Surname *

Date of birth *

Address *

Postcode *

NHS Number/Hospital Number/Booking Reference*

GP Practice*

Contact details

Telephone

Mobile number*

Email address *

Preferred method of contact

If mobile number supplied, are you happy to receive reminders about your appointment via text message:

Yes
No

I would like to:

Book a new appointment
Rearrange an existing appointment or cancel my appointment

Any other message

Consent

We will use the information provided for the purposes of processing your request to book, cancel or change your outpatient appointment. We will not pass your details onto third parties. For full details of how we collect and use your information, see our Trust privacy notice.

I consent to my information being used as described above *

I accept that the information entered in this form will be sent as an email (emails are not a secure form of communication). *