Skip to main content

Cookies on the Wycliffe Surgery website

We've put some small files called cookies on your device to make our site work.

We would also like to use google translate cookies and analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

You can change your cookie settings at any time using our cookie policy.

Wycliffe Surgery

Home
My Devon Health
Practice Staff
Contact Us
New Patients
Enquiries
Medication
Latest News
Services
Health Advice
Online Health Reviews
SYSTMONLINE - Patient Login
Contact Us Online

New Patients
Enquiries
Medication
Latest News
Services
Health Advice
Online Health Reviews
SYSTMONLINE - Patient Login
Contact Us Online

Home
My Devon Health
Practice Staff
Contact Us

New Patients!

Now accepting out of area patients, go to New Patients to register with us now...

Find out more

Dismiss

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 *

Oops... There was an error contacting reCAPTCHA, Please try again.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Further Information

FEEDBACK
Data Protection - GDPR
Patient Record
CQC Report
GP Earnings
Practice Policies

Add Footer Link

Sign in

© 2024 Built by My Surgery Website
Accessibility
Cookie policy
Your data
Site map

Translate this website with google