PALS contact form (including Easy Read)

PALS is not an emergency service and if you are contacting us regarding for medical reasons please call 111 or 999.

Are you the patient?*

Patient's details

Patient's name*

Firstname Surname

Patient's date of birth*

Patient's NHS number

Patient's phone number*

Patient's email address*

Patient's address*

Address line 1 Address line 2 Town County Postcode

How would you like us to contact you?*

If you are not the patient, what is your name?

Firstname Surname

As you have advised you are not the patient, please provide your relationship to the patient?*

Your phone number*

Your email address*

Your address*

Address line 1 Address line 2 Town County Postcode

How would you like us to contact you?*

What is the name of the service/team you are contacting us about?*

I would you like...*

To cancel or re-arrange an appointment you will need to contact the service you are contacting us about for them to complete this.

Please tell us as much detail as you can so that we can ensure your compliment reaches the right person and or team*

Please tell us as much detail as you can so that we can help you in the best way possible*

If we note that we are not the correct trust/organisation are you happy to consent for us to forward your contact on to the correct one?*

CAPTCHA