Request to cancel or defer surgery

Your details

NHS number

Full name*

Address*

Date of birth (DD/MM/YY)*

Telephone (home)*

Telephone (mobile)

Email*

Consultant name if known

Department

Reason for cancellation/deferral request*

I no longer need/require the surgeryI have had the planned surgery elsewhere (please specify where in box below)I would like to defer my surgery until after covidI would like to defer my surgery for other reasons (please specify why and for how long in box below)

If other, please specifiy why: