Change of Breast Screening Appointment Request Form

Please complete the online form below if you have received a date for a breast screening appointment that you would like to change.

Fields with an asterisk must be completed.

Surname*

First name*

PBO number* (This is the six digit number following PBO at the top of your invitation letter.)

Your email*

Date of birth
DAY ---- MONTH --------------- YEAR

Preferred day for appointment*

Please note that we will do our best to accommodate your request but cannot guarantee that an appointment will be available on your chosen day.

Morning or afternoon?*

Please state a second choice for day of appointment in case your first choice is not available.

Morning or afternoon?

Please indicate here if you wish to change where you will be screened.

Comments

Your information is processed in accordance with the General Data Protection Regulation and Data Protection Act 2018.

Visitor restrictions

To protect you and our staff during the current outbreak of Covid-19 we’ve put in place significant restrictions on hospital visitors.

Full details of these can be found on our website.

We would like to thank you for your understanding and helping us stop the spread of Covid-19.

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