PALS Request Form

Your full name *

Your email address

Your telephone number

Are you a *

Patient

Relative

Carer

Other

If you are a patient, please provide your Hospital Number (MRN number) and date of birth *

If you are a relative, are you Next of Kin *

Yes

No

If you answered 'other', please provide details *

I would like to request

A call from PALS about a concern

To meet with a PALS Advisor

To raise a formal complaint

Access to medical records

Lost Property Form (claim)

Change an appointment

Please provide any further information and/ or questions

*

Preparing for your visit with us: Before you arrive, during your stay and how we'll look after you