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
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 EardleyMr HarrisMr RahmanMiss Anna WrightMr ElmamounMr CartledgeMr WongMr MuftiMr GordonMr Devlin Mr BiyaniMr KimuliMr PalitMr PaulMr JainMr KotwalMr CrossMr Prescott
If no, reason for cancellation Select Date not SuitableAway on HolidayToo short noticeOperation not needed/wantedTreated elsewhereMedically unfit for surgery
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