APPOINTMENT CANCELLATION REQUEST FORM

You may use this form to cancel an appointment at any time up till 8.00am on the day of your appointment. After 8.00am on the day please phone 08444 773 005 to cancel an appointment.

If you experience any problems with this form please let us know.

* = Indicates required information.

CANCELLATION REQUEST *First Names: *Last Name: *Date of Birth (dd/mm/yyyy): *Phone: Landline: Phone: Mobile: *Email: Appointment details:   *With: Please Specify... Dr Aldridge Dr Bidston Dr Brown Dr Chevassut Dr Choi Dr Gutmann Dr Haynes Dr Hicklin Dr Hislop Dr Kaur Dr King Dr Madgwick Dr Marshall Dr Monk Dr Pimm Dr Quli Dr Sharpe Dr Shaw Dr Tulley Dr Weeks Practice Nurse Health Care Assistant Midwife Other *Date: *Time: CONFIDENTIALITY - TERMS AND CONDITIONS: The internet is not secure, and the transmission of data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions. We cannot enter into correspondence via email. *I accept the terms and conditions above

An automatic reply will be sent to confirm receipt of your cancellation.
To make a new appointment please phone 08444 773 005.