*boxes marked with an asterisk, must be filled in

Your details

*Your Name             Where do you come from?  

*Your email address                                                       (Town or Area)

Recipient

*To whom would you like this piece of music played?   

Which ward?   

          Add a few words (max 20) for that personal touch

                                                               .

Your request

1st choice

Music Title       (and/or) Artist or Composer   

2nd choice

Music Title       (and/or) Artist or Composer   

3rd choice

Music Title       (and/or) Artist or Composer   

OR

Lucky Dip    (state type of music)       Non selected Pop Rock Folk From the Shows Classical Opera Romantic Easy Listerning  or other  

When do you want it played?

<< click on the small calendar to select a date

                                                                                                         or enter the Day, Month and Year

What time would like your request played?    No time selected 8pm (20:00) 8.15pm (20:15) 8.30pm (20:30) 8.45pm (20:45) 9 pm (21:00) 9.15pm (21:15) 9.30pm (21:30) 9.45pm (21:45) 10pm (22:00)

Whilst every attempt will be made to play your request as near to your specified time as possible, this cannot always be guaranteed.  If we are unable to play your request because of late programme changes or other circumstances beyond our control, we will endeavour to contact the patient(s) concerned to minimise any disappointment.

To view the programme schedule, <<click here>>