Ethnicity Data Form

In line with government guidance, we are asking our patients to inform us of their ethnicity to complete their medical record. Covid-19 has affected certain populations in the UK differently, so in order to plan recovery in a way that inclusively supports those at greater risk, it is important we have this data on record.

Are you completing this form on behalf of:

Yourself

Someone else (e.g. a child or dependent)

About the patient

Name

First – As it appears on the patient’s passport. Last – As it appears on the patient’s passport.

Postcode

The one you used to register with your GP.

Patient Date of Birth

DD slash MM slash YYYY

Patient’s date of birth is required to verify their identity.

Sex

Male

Female

Other

About You

Your Relationship to Patient:

Postcode

Patient Date of Birth

DD slash MM slash YYYY

Patient’s date of birth is required to verify their identity.

Sex

Male

Female

Other

Your Phone Number

The practice may use this number to contact you about your request.

Your Email

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.