Dear Insert Patient Sname

Dear[insert patient’sname]

UR number:[insertUR number]

Wearecontinuallymonitoringandupdatingourelective surgery waitlistsoitremainsaccurate,completeand ensurestimelyaccesstoourservices.Toassist us inkeepingourwaitinglistaccuratewerequest that you completethesection over the pageand return it inthe envelope provided within 10 days.

Weacknowledgethatyoumayhavepreviouslyreceivedandrepliedtothisrequest,andapologise foranyinconveniencecaused,howeveritisimportantthatthisinformationisobtainedregularlyand ourrecordsupdated.

Ifyourequireattentionforyourconditionwhilewaitingforyourpre-admissionclinicalappointment orproceduredateweurgeyoutocontactyourGP,orinanemergencyattendyournearest hospitalemergencydepartment.Changesinyourconditionorgeneralhealthmayhaveimplications forthetiming ofyourprocedure orleadtoyourclinical prioritycategorybeing re-assessed.

Ifyoudonotconfirmthatyouwishtoremainonthelistwithin10workingdaysofreceivingthis letter,oneotherattemptwillbemadetocontactyou.Ifthereisstillnoresponseyou mayberemovedfromthe hospital’swaitinglist, in consultation with your doctor.

Shouldyouhaveanyqueriesrelatingtotheinformationprovidedinthisletter,pleasecontactthe hospitalon[insertcontactnumber]between9.00AM-4.00PMMondaytoFriday;alternativelyyou can speakwith the hospital patient liaison officer.

Yourssincerely

[Insert hospital]

[Insertcurrent date]

Please complete the following section:

Do you still require your procedure? YES NO

If you ticked NO, please indicate the reason:

I have already had the procedure

I no longer require the procedure

I no longer wish to have the procedure

Other (please specify): ______

Current contact details

Address: ______

Phone number: Home:______Mobile:______

Work: ______

Current GP details

Name: ______

Address: ______

Phone no.: ______

Thankyoufortakingthetime tocompletethisform.Please sign below and return itin theenvelope providedwithin 10workingdays.

Patient/CarerName:Patient/CarerSignature: ___

Date:_____/___/