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Including Ethnicity In Your Health Records
Information about your ethnicity helps us make sure we provide the highest quality of care for all patients. Studies show that our racial and ethnic backgrounds may place us at different risks for certain diseases.
Please submit the form below so we can make sure your ethnicity is included in your medical record.
The information you provide will be treated as part of your confidential medical record and will not be shared with any other person or organisation. The NHS has strict standards regarding data protection and your information will be carefully safeguarded.
Once we have told us your ethnic group, we do not need to ask you these questions again. The information regarding ethnic origin will be released only in the form of total numbers and no individual can be identified from the statistics.
Last Updated: 10/06/2022
Patient Details
First Names
*
Last Name
*
Date Of Birth DD/MM/YYYY
*
Your Phone Number
*
Your email
Ethnicity
*
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ehnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Prefer not to state
Not known
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