New Patient Registration Form / Health Questionnaire Date form Completed Please complete all parts of this form and take to Reception at either surgery along with the ID as detailed in this document. Please complete this form electronically or write in CAPITALS. Title Surname First Name Current Address Postcode: Date of Birth: Marital Status Occupation Language(s) Spoken Ethnicity Information on ethnicity is important because of the need to take into account culture, religion and language in providing appropriate individual care, changing legislation, the importance of providing information on ethnicity for shared care including secondary care and the need to demonstrate and equal outcomes. I would describe my ethnic origin as: Asian or Asian British Black or Black British Mixed African White and Asian Bangladeshi Caribbean White and Black African Indian White and Black Caribbean Any other Black background Pakistan Any other mixed background Any other Asian background Other Ethnic Group White Non-disclosure Chinese British I do not wish to disclose my Any other ethnic group Irish ethnic origin Any other White background Contact Details
New Patient Registration Form / Health Questionnaire Please complete all parts of this form and take to Reception at either surgery along with the ID as detailed in this document. Please complete this form electronically or write in CAPITALS. Date form Completed Title Surname First Name Current Address Postcode: Date of Birth: Marital Status Occupation Language(s) Spoken Ethnicity Information on ethnicity is important because of the need to take into account culture, religion and language in providing appropriate individual care, changing legislation, the importance of providing information on ethnicity for shared care including secondary care and the need to demonstrate and equal outcomes. I would describe my ethnic origin as: Asian or Asian British Black or Black British Mixed Bangladeshi Indian Pakistan Any other Asian background African Caribbean Any other Black background White and Asian White and Black African White and Black Caribbean Any other mixed background Other Ethnic Group White Non-disclosure Chinese Any other ethnic group British Irish Any other White background I do not wish to disclose my ethnic origin Contact Details
Adult%20Registration%20Form%20Nov%202016.docx