Outpatient Appointment Change Request

Outpatient Appointment Change Request

You can re-arrange your outpatient appointment online by completing this form. Please be aware that any emails you send to the University Hospital of North Staffordshire, and those which we may send to you, are not guaranteed to be secure as email messages may be intercepted.

If you prefer not to use this system please telephone the appointments department on 01782 555444 instead. The questions with a star * must be completed, others are optional.

Appointment Centre Opening Times

The Appointment Centre is open Monday - Friday 08:00am until 18:00pm and Saturday 09:00am until 13:00pm

Telephone: 01782 555444

Name:*

Address Line 1:*

Address Line 2:*

Town/City:*

County:*

Post Code:*

Telephone number:

Date of Birth:*

Previous appointment date:*

Name of your GP:*

Choose and Book reference number (if you have one):

Unit No./Hospital No. (if known):

NHS No. (if known):

Consultant's name/specility:

Your email address:*

Any further comments:

* required

Thank you for completing this form. We will send your amended appointment by e-mail. Besides choosing the hospital where you want to be treated, you can also choose your appointment time so, if the appointment we send you is not convenient, please let us know and we will e-mail another date and time to you. If we do not hear from you within the next 7 days we will assume the date given to you is suitable.

Please click on the submit button to send your form.

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