Ethnicity Data Form

It is important that we have your ethnicity on your record. Covid-19 highlighted that some conditions can affect ethnic groups differently. Recordng this information helps us to identify the different risk levels for our patients and plan accordingly.

Please select the practice location most relevant to this Online Form submission:

Ethnicity Data Form

Are you completing the form for yourself or a someone else?

If someone else please specify your relationship to them

If you are completing the form for someone else, put their information in the patient details section and your contact details in the contact information section

Patient Details

Title

First Name

Surname

Date of Birth

Address

Post Code

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Plumstead (Main Branch) • Plumstead (Main Branch), 44 Conway Road, Plumstead, London, SE18 1AH .

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Key Information

BBC Health News

Ethnicity Data Form

Privacy Protection

Plumstead (Main Branch)

Welling (Branch Site) - Temporarily Closed Until Further Notice