Full Name

Does the person you are registering consider themselves to have a disability? Yes No

Gender at Birth Male Female Not Known

Gender Identity Male (including trans male) Female (including trans female) Non-binary Prefer not to say

Date of Birth

Age

House Number

Postcode

Sexual Orientation Heterosexual (straight) Gay Lesbian Bisexual Unsure Patient declined to answer Patient was not asked None of the above

Which of the following best describes your ethnic group? White British White Irish Other white background Mixed - white and black Caribbean Mixed - white and black African Mixed - other Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Any other Asian background Black or black British - Caribbean Black or black British - African Any other black background Chinese Any other ethnic group

Country of Birth

Please read the following data information to the person registering:

The information you are providing will be shared with Midlands Partnership University NHS Foundation Trust. Your information will be used to create an electronic sexual health record which is confidential and not shared with other services, unless we have reason to believe you or someone else is at risk of harm and the information in this form is relevant to keeping you safe. If you would like more information relating to your rights and the Trust, visit https://www.mpft.nhs.uk/about-us/information-governance

Confirm that person gives consent