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Ethnicity Questionnaire

This form is for patients of Wickham Market Medical Centre and Rendlesham Surgery only. If you are not a patient of either of these practices please exit this form.

We would be grateful if you would provide details below. Further details  can be found at this NHS Digital page (opens in a new window).

Personal Details

Allow us to send texts via SMS to you

Do you consent to SMS?

Do you consent to SMS?

Ethnicity

Please indicate your ethnicity:

Please indicate your ethnicity:


Confirm your Location

Information provided by you through this form will allow us to improve our services. The form data undergoes encryption during transmission and while at rest, and will only be retained for a duration sufficient to process your request. You have the option to withdraw your request at any time by notifying the practice. By using this form you are agreeing to our privacy guidelines.

Send Your Request

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