Weightmans’ Patients’ Award – Nomination form

You can download and print off a nomination form here

    Part 1: About your nominee:

    Name of your nominee for Weightmans' Patients' Award:

    Job title of your nominee (e.g. doctor, nurse, physiotherpaist, medical secretary, volunteer, etc):

    Your nominee's ward or department:

    At which hospital or health unit did you, your friend or relative receive care from your nominee?

    In no more than 200 words, please explain why your nominee deserves the Weightmans' Patients' Award:

    Part 2: About You:

    Your Name (forename and surname):

    Your address (including postcode):

    Your daytime telephone number:

    Your Email: