PALS online form

Please be factual in your feedback. It is helpful if you provide us with specific information if you know it, such as names of staff involved and where the incident happened.

If you are contacting us on behalf of someone else, we will need their permission for you to act on their behalf. We can do this over the telephone or by speaking to them in person.

Patient details:

Title:*

First name:*

Last name:*

Postal address including postcode:*

Contact number:

Email address:

Date of birth:

NHS number (if known):

Your details (if you are not the patient):

Title:

First name:

Last name:

Postal address including postcode:

Contact number:

Email address:

What relationship are you to the patient?

Which site did the issue take place:*

Which ward did the issue take place:

Date the issue took place:*

Please summarise the issue that has led you to contact PALS:*

Any additional information:

What would you like to happen as a result of you contacting PALS? Please note that if we do not think that we can achieve what you want, we will let you know.

Other:

What is your preferred method of communication?

Other:

The information I have provided is accurate to the best of my knowledge.*

* required fields

Update for visitors

Visiting restrictions are in place at our hospitals to stop the spread of norovirus. These restrictions will be in place until further notice.

The following wards are closed to visitors:

York Hospital: Ward 29 and Ward 37.

There are four exceptions only to the restrictions. These are:

For patients who are receiving end of life care

Paediatric patients (babies and children)

Maternity care

The family carers of those with dementia

We understand these restrictions can be difficult when a loved one is unwell. The restrictions will be reviewed daily and lifted as soon as it is safe. Thank you for your understanding as we try to reduce the spread of norovirus in our hospitals.