Recording Of Your Ethnic Group

Please complete this form to let us know your Ethnicity.

Recording Of Your Ethnic Group Questionnaire
This practice, in line with other healthcare providers and all other statutory services such as local authorities etc, now collect information about the ethnic group of patients. This information will help us learn more about patients’ needs and then allow us to plan services to meet the health needs of the entire community and ensure that everyone has access to healthcare services which meet their needs.
 
Please note we are not asking about citizenship or nationality, but about the ethnic group to which you feel you belong. All the information we receive will be used and treated with the strictest confidence. Any planning information on general release will be anonymous with all the names removed. The classification is entirely voluntary but will help us provide a service that will meet individual and local community needs. The level or quality of care you will be offered by NHS Islington will not be affected by your decision to complete this form.
 
If you have any queries about completing this form, please ask a member of staff.
 
Otherwise, please complete the form below by ticking the box of the ethnic group to which you feel you belong. If you feel you are descended from more than one group please tick the one you feel you most belong to, or choose the Any Other Ethnic Group option. The groups used below have been developed and agreed by the Office of National Statistics in conjunction with the Commission for Racial Equality.
Have you read and fully understood the above information? *
Please contact reception for further guidance. 

Patient Details

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Language

Do you speak English? *
Do you need an interpreter? *

White British

Please select an option:

Other White European

Please select an option:

Mixed

Please select an option:

Asian or Asian British

Please select an option:

Black or Black British

Please select an option:

Other Ethnic Groups

Please select an option: