Cancel an Appointment

Please use this form to notify us if you need to cancel your GP appointment so that we can allocate the time to another patient. Please give as much notice as possible when cancelling appointments online.

If your appointment is today, please telephone the surgery on 0121 526 2233.

Your Details

Title

First Name

Surname

Date of BirthDD/MM/YYYY

Are you able to provide your NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

Your Address

Address

Post Code

Your Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

Appointment Details

Your GP

Date of AppointmentDD/MM/YYYY

Time of AppointmentHH:MM

Comments

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Rough Hay Surgery (Training Practice) • 44b Rough Hay Road, Darlaston, West Midlands, WS10 8NQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Local Services