Please complete the form below to notify us of your cancellation request.

If your appointment is today, please call the Contact Centre on 01904 726400.

Your details

NHS number

Full name*

Address*

Date of birth (DD/MM/YY)*

Telephone (home)*

Telephone (mobile)

Would you like to receive text reminders of your appointment*

YesNo

Email

Your existing appointment

Date of appointment (DD/MM/YY)*

Hospital*

Bridlington HospitalMalton Community HospitalNelsons CourtScarborough HospitalSt Monica's EasingwoldThe New Selby War Memorial HospitalWhite Cross CourtYork Hospital

Time of appointment*

Consultant name

Department

Reason for the cancellation*

Can't make the day/timeAppointment no longer neededNot well enough to attendOther

If other, please specify why:

Re-booking your appointment

Would you like to re-book another appointment?*

YesNo