Contact our Patient Advice and Liaison Service (PALS) 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 Please Select An Option White BritishWhite IrishWhite OtherBlack CaribbeanBlack AfricanBlack OtherIndianPakistaniBangladeshiAsian OtherWhite & Black CaribbeanWhite & Black AfricanWhite & AsianMixed OtherChineseOtherPrefer not to say *This is a mandatory field. Do you have a disability? Please Select An Option YesNoPrefer not to say 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? Please Select An Option Birmingham Children's HospitalBirmingham Women's HospitalMental Health Services *This is a mandatory field. Department/hub (e.g. Emergency Department, Gynaecology) *This is a mandatory field. Reason for your contact Please Select An Option Compliment EnquiryConcern *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: Is a stop sign red or blue?
