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Wycliffe Surgery

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Services
Health Advice
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SYSTMONLINE - Patient Login
Contact Us Online

My Devon Health
Practice Staff
Contact Us

Important!

We will be running covid clinics on the 30th of November and 8th of December, click here to find out more...

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Ethnicity Form

Last Updated: 23/06/2022

Ethnicity Form

PLEASE COMPLETE FOLLOWING QUESTIONS IN FULL

Please select from the following options:

I am the patient named on the registration form

I am completing the registration form on behalf of the patient named

YOUR DETAILS

*If the question is not applicable or the answer is unknown, please state N/A or UNKNOWN

Title *

Surname *

First name(s) *

Date of birth *

CONTACTING YOU

We may need to contact you from time to time, with important practice news, advice about your health and/or appointment reminders.

Do you consent to be contacted by text message (sms)? *

Yes No

Mobile Number

Do you consent to be contacted by e-mail *

Yes No

Email address:

YOUR ETHNICITY & LANGUAGE

The NHS requires all medical records to show patient ethnic origin/ native or first language

Ethnic Group *

White British

White Irish

White Other

Black British

Black Caribbean

Black African

Black Other

Asian Indian

Asian Pakistani

Asian Chinese

Asian Other

White & Black British

White & Black Caribbean

White & Black African

White & Asian

Other

What is your first language? *

Do you need an interpreter? *

Yes No

Signature

I confirm that all the information I have provided about myself (on behalf of patient) is correct *

Yes

Relationship to patient if signing on their behalf

Date *

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