Including ethnicity in your health record

Information about your race and ethnicity helps us make sure we provide the highest quality of care for all patients. Studies show that our racial and ethnic backgrounds may place us at different risks for certain diseases.

Please submit the form below so we can make sure your ethnicity is included in your medical record.

All messages will receive an email response (to the input address) – please check your email address given and junk/spam folder if you do not receive a response.

Ethnicity Questionnaire


Please specify the ethnic group you consider you belong to: