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Stonecot Surgery NHS GP Surgery in South West London

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Please specify the ethnic group the patient belongs to: *

White: British

White: Irish

White: Gypsy or Irish Traveller

White: any other white background

Asian or Asian British – Indian

Asian or Asian British – Chinese

Asian or Asian British – Pakistani

Asian or Asian British – Bangladeshi

Asian or Asian British – any other Asian background

Asian and Chinese

Black or African or Caribbean or Black British – African

Black or African or Caribbean or Black British – Caribbean

Black or African or Caribbean or Black British – any other black African or Caribbean background

Mixed multiple ethnic groups: White and Asian

Mixed multiple ethnic groups: White and Black African

Mixed multiple ethnic groups: White and Black Caribbean

Mixed multiple ethnic groups: any other mixed or multiple ethnic background

Other ethnic group

Other ethnic group: Arab

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Terms and Conditions

I understand that it is my responsibility to keep my account secure by keeping my details confidential
I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records
I understand that my registration will be revoked if I constantly miss or cancel appointments.

I accept the terms and conditions stated above

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115 Epsom Road
Sutton
Surrey
SM3 9EY

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0208 644 5187

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