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PALS Test

Your details

Full name*

Date of birth (DD/MM/YY)*

NHS Number (if known)

Text message hospital appointment reminder service

Would you like to recieve text reminders of your appointment*

If you have said yes to the above, please provide your mobile phone number

Communication support needs

We are keen to ensure that people who have a disability, impairment or sensory loss are given their information in a format they can easily read or understand.

Would you consider yourself to require written communication support?

If you have answered yes, please indicate which of the following you would prefer your written correspondence in:

If you have chosen email, please provide your email adress

Do you require communication support when attedning hospital appointments?*

If yes, what type of support do you require

If you require a foregin language interpreter, please specify language

Please specifiy here if your require any other form of communication sport

Sign up to receive hospital communications via email

In 2018, we will be be able to offer you the option to receive hospital correspondence by email rather than post. PLease indcate below if you would or would not like this as your preference.

Yes I would like to recieve email correspondance

No I would not like to receive email correspondance

At this time, I am unsure if I would like to receive email correspondance

If you have chosen yes to receiving email correspondance, please provide your full email address


I understand that by completing and submitting this form, I am giving permission for York Hospital NHS FOundation Trust to send me text reminders and email communications if I have selected these options*

Email 2*:

* required fields

 

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