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Cancel an Appointment

This form may be used to cancel and reschedule an appointment with a physician at Cooper Clinic. Your cancellation request will be confirmed by email reply.

If you request your appointment be rescheduled, you will be contacted BY PHONE, usually the same day we receive your email. (Note: Our call may not appear as "Cooper Clinic" on Caller I.D.) If you prefer, you may call your physician’s office directly.

Patient Name:
Parent or Guardian (if patient is a minor):
Patient's Date of Birth:	/ /
Patient's Email Address:

Appointment to be Cancelled:
Please Select a Physician OR a Department (Complete sections 1 or 2 below)

Physician?:

If you do not know your physician's name
please proceed to step 2.

Select a Physician:

The physician you selected above practices in the following department:

If you did not select a specific physician above
please select the appropriate department:

Reason for Cancellation:
Appointment Date:	/ /
Appointment Time:

Rescheduling an Appointment
If you wish to reschedule your appointment, please submit the following information and you will be contacted BY PHONE, usually the same day we receive your email.

Preferred time of day to be called:
Phone numbers where you can be reached during your preferred time:	- or: - Note: Our call may not appear as "Cooper Clinic" on Caller I.D.