Ethnicity Data Form - Burney Street Practice

In line with government guidance, we are asking our patients to inform us of their ethnicity to complete their medical record.

Covid-19 has affected certain populations in the UK differently, so in order to plan recovery in a way that inclusively supports those at greater risk, it is important we have this data on record.

Are you completing this form on behalf of:

Yourself

Someone else (e.g. a child or dependent)

About the Patient

Patient's Name

First Last

As it appears on the patient’s passport.

Patient's Date of Birth

Patient's Sex

Male

Female

Other

As on the patient’s medical record.

Patient's Current Address

Street Address Address Line 2 City Postcode

The one you used to register with your GP.

About You

Your Name

First Last

Your Relationship to Patient

Your Current Address

Street Address Address Line 2 City Postcode

Your Date of Birth

Contact Number

The practice may use this number to contact you about your request.

Email Address

Enter Email Confirm Email

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Ethnicity Data

Your Ethnicity