Your details
Name
Required
Address
Required
E-mail address
Required
Telephone
Required
Date of birth
Do you have any specific communication requirements?
Required
Patient NHS number (if known)
Patient hospital number (if known)
Patient details
(If you are not the patient)
Name
Address
Contact Telephone Number
Email address
Date of Birth
Date
NHS Number (if known)
Hospital Number (if known)
Organisation or service this enquiry is about
Please provide details of the issue you wish to raise below. Please include details such as the organisation, department or service, member(s) of staff, date of incident/issue if known.
Required
PALS asks for additional information for monitoring purposes but you do not have to provide this.
Gender
Male Female Nonbinary
Ethnicity
Are you a carer?
How did you hear about PALS?
I give my consent to North of Tyne PALS, and staff who are involved with or responsible for my care and treatment, to access and share any information which is relevant to the issues which PALS is pursuing on my behalf.
Please note if the issue is about someone else PALS may need to contact them to gain their consent.
If you choose to be contacted by email please find below some guidance about using email and the security risks involved when providing personal and/or confidential information.Email contact Disclaimer
We recognise that email is a convenient and preferred method of communication for many people however prior to responding to your queries via email we would be grateful if you could read the information below and confirm by replying to this email that you are happy to communicate in this way.
You should be aware that not all email services are encrypted and as such are not secure when they travel along the internet; they can be intercepted, read or amended without the knowledge of the sender or intended recipient. This may lead to a breach of your confidentiality. Also, we cannot ensure that the intended recipient is the only reader of any emails in circumstances where households share email addresses and therefore unintentional access to private information could take place.
I would therefore be grateful if you could please confirm you fully understand the risks involved with email communications from North of Tyne PALS via email to enable us to continue communicating with you via this method.
I would like to communicate with North of Tyne PALS by email. I confirm that I understand that email services are not a secure medium. I also understand that there is a possibility that my emails and the responses could be intercepted and read by someone else. I will bear this in mind in deciding how much information to seek and how much information to disclose by email.
If, at any time you no longer wish to be contacted via email, please contact North of Tyne PALS at PALS@northumbria-healthcare.nhs.uk or telephone Freephone 0800 0320202
For further details on how we use your information or if you have any issues or any questions please access the following link .
