End my Maternity Care Episode

Thank you for letting us know you no longer wish to receive maternity care at Guy's and St Thomas. Please fill out the below form in order for us to cancel all future appointments.

1. Name *

First Name	*
Last Name	*

Previous Surname (If applicable)

2. Address *

Street Address	*
Line 2
Town	*
County	*
Postcode	*

3. Preferred contact number *

4. Date of Birth *

	DD/MM/YYYY

5. Please complete the following - (we will not be able to close your episode of care without this information): *

Hospital number
NHS Number

6. Reason for ending care with Guy's and St Thomas Maternity Department *

Change of home address
Decided to transfer/ book for maternity care with another hospital provider
Spontaneous Miscarriage
Ectopic pregnancy
Termination of pregnancy
Other (please specify):