My Outpatient Appointment

Please fill in the form below so that we can identify you and find your appointment.

If you have already missed your appointment, do not complete this form. You will need to contact your GP surgery for further advice.

This form must be completed at least 24 hours before your scheduled appointment.

Don't forget to click the submit button at the bottom of the page once you have finished filling in all the required fields.

Please note this online form is secure.

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Outpatient appointment form

About you

First name »

Last name »

Date of birth (DD/MM/YYYY) »

NHS number

Trust ID number

Your NHS number and the Trust ID number can be found on your appointment letter.

Your appointment

If your department does not appear here, please call switchboard on 01273 696955

Department »

Hospital site »

Date of appointment »

Time of appointment (24 hour clock, i.e. 13.00)

Enter your appointment time as stated on your letter.

What would you like to do?

I want to: »

RESCHEDULE - I would like to move this appointment. If this is the 2nd time you are rescheduling you may be discharged back to your GP.
CANCEL - I no longer need this appointment.

Phone number and/or email (best contact) »

Any other comments:

If necessary we will contact you between 9.00am - 5.00pm, Monday to Friday

Please note - successful submission of your request will be confirmed with the appearance of a thank you message.