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Rainbow Medical Centres NHS GP Surgeries in St Helens

Including ethnicity in your health record

Ethnicity Data

Required fields are labelled

Who are you completing this form for? Required

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

Ethnicity

Please specify the ethnic group you consider you belong to: Required

White – British

White – Irish

Gypsy or Irish Traveller

Any other White background

Mixed White and Black Caribbean

Mixed White and Black African

Mixed White and Asian

Any other Mixed / Multiple ethnic background

Asian or Asian British – Indian

Asian or Asian British – Pakistani

Asian or Asian British – Bangladeshi

Any other Asian background

Black or Black British – African

Black or Black British – Caribbean

Any other Black / African / Caribbean background

Chinese

Arab

Other ethnic group

I do not wish to state

Please specify: Required

If you are human, leave this field blank.

The Sutton Surgery
333 Robins Lane
Sutton
St Helens
Merseyside
WA9 3PN

Get directions

01744 811211

Thatto Heath Surgery
99 Elephant Lane
Thatto Heath
St Helens
Merseyside
WA9 5QL

Get directions

01744 811211