Cancel an Appointment

Please let us know as soon as possible if you are unable to make your appointment by completing the form below. In future you may wish to register for online services to have the ability to Book or Cancel an Appointment, Request a Repeat Prescription, Change Personal Details and View your Medical Records without visiting the Surgery.

Patient Details

Patient's Full Name *

Patient's Date of Birth (DD/MM/YYYY) *

Email Address *

Mobile Phone Number

Landline Phone Number

Appointment Details

Appointment Type *

Name of Doctor or Nurse/HCA (if known)

Appointment Date (DD/MM/YYYY) *

Appointment Time *

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 29 January 2023
Page created: 13 October 2026

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Cancel an Appointment

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