T:+ (44) 0303 303 0303F: +(44) 0207 284 8226Emergency: + (44) 07710 599161E: donorprovision@anthonynolan.orgRegistered charity number803716/SC038827

ANTHONY NOLAN2 Heathgate Place75-87 Agincourt RoadLondon NW3 2NUwww.anthonynolan.org

Notification of Change:

Please state whether this is a cancellation or postponement here:

Donor ID

Patient Name

Transplant Centre recipient ID

Anthony Nolan recipient ID

International registry recipient ID

Please state reason here:

We wish to…* Cancel Postpone*(delete as appropriate)

Expected length of postponement / new requested date: ……………………………..

Completed by (Print name) ………………………………………………

Signature …………………………………………………………………..

Date ………………………………………………….…………………….

Please acknowledge receipt of this form and return.

Received on ………………………………………………………………..

Received by (Print name) ………………………………………………..

Signature …………………………………………………………………..

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