Contact PALS form

Contact form

Note: Questions marked by * are mandatory

In accordance with the General Data Protection Regulation (GDPR), in force from 25 May 2018 by submitting this form you agree for your data to be used for the purposes of processing your enquiry only.

Patient details

*This is a mandatory field. Name

*This is a mandatory field. Date of birth

*This is a mandatory field. Email address

*This is a mandatory field. Contact number

NHS Number

Hospital number (if known)

*This is a mandatory field. Ethnicity

*This is a mandatory field. Do you have a disability?

Please note, if you are reporting concerns regarding a young person or partner that is over 16, consent will need to be provided. If possible, they can contact PALS directly to provide this.

Contact details (if you are not a patient)

Name

Email address

Contact number

Query information

*This is a mandatory field. Where is your query related to?

*This is a mandatory field. Department/hub (e.g. Emergency Department, Gynaecology)

*This is a mandatory field. Reason for your contact

*This is a mandatory field. Summary of your compliment/enquiry/concern

*This is a mandatory field. Expected outcome

I'm seeking more information
I'm sharing for your information only
Seeking an apology
Other

If other, please state

* Spam Guard: What is the next number after 5? Write the number as a word.

Contact PALS form

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