Your Speech & Language Therapy Appointment

Please only complete this form if you have a letter asking you to do so.

We are undertaking a review of all patients on the Speech and Language Therapy appointment waiting list and would like to understand whether you still need an appointment to be booked. You may have been referred to Speech and Language Therapy due to concerns about your communication and/or swallowing.

If you have significant changes in your symptoms relating to your condition, please speak with NHS 111 or your GP.

Please provide these details so we can find your records:

First name:

Last name:

Date of birth:

Postcode:

Hospital number:

NHS number:

Do you still need an appointment with a Speech and Language Therapist?

Yes

We will offer an appointment as soon as possible, thank you for your patience.

Whilst you wait for an appointment, have a look at our online information page, with useful links to help you manage your symptoms. This page will be shown once you have submitted this form.

Please tell us why you no longer need an appointment:

I have been treated elsewhere and no longer wish to have the appointment at Southmead Hospital. I am happy to be discharged.

My symptoms have resolved and I am happy to be discharged.

My symptoms have not resolved, but I no longer wish to have the appointment. I understand that I will be discharged.

You will be discharged from our service.