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PALS contact form

Please note that the contents of this form will not be encrypted upon submission. If you would prefer not to use this form to submit your information, please contact PALS

Telephone 0121 424 0808 (Monday to Friday 09:00am – 3:30pm). There is a voicemail facility outside of these times.

    Name of the person making contact

    Name of person contact relates to-if different

    Hospital Number-if known

    Relationship to Patient - if different

    Patients Address

    Patients Date of Birth

    Contact telephone number

    Alternative telephone number

    Email address

    What is the best time to contact you?

    Reason for contacting us

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