Ethnicity Collection Form We are required to have up to date ethnicity information for our patients and would appreciate if you could indicate your ethnicity below.
Name: ____________________________________________ Date of Birth: ___ / ___ / ___
New Zealand European
Ethnicity Details Which ethnic group(s) do you belong to? * Tick the space or spaces which apply to you
Maori Samoan Cook Island Maori Tongan Niuean Chinese Indian Other (such as Dutch, Japanese, Tokelauan). Please state:
Signed: ___________________________________ Date: ___ / ___ / ___ Western Bay of Plenty PHO – Ethnicity Collection Form. Last Update August 2018