Please complete the form below to accept or decline the date for your operation. Please note that all fields are mandatory.
Are you the * Select PatientRelativeCarerOther - acting on behalf of patient
Patient to enter the following details:
Forename *
Surname *
NHS Number (10 digits / no spaces) *
Date of Birth (DD/MM/YYYY) *
Address *
Postcode*
Telephone (home) *
Telephone (mobile) *
These details can be found in your letter:
Admission date (DD/MM/YYYY) *
Consultant * SelectMr Richard BakerProfessor Pete SagarMr Dermot BurkeMr Aaron QuynMr Rick SaundersMr Ian BotterillMr Kallingal RiyadMr Jim TiernanProfessor David JayneMr Julian HanceMr Sushil MaslekarMr Chin AngMiss Nasira Amtul
If no, reason for cancellation Select Date not SuitableAway on HolidayToo short noticeOperation not needed/wantedTreated elsewhereMedically unfit for surgery
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