Weight Management Self-Referral Form

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To complete this form you will need your height, weight and BMI. You can check your BMI here BMI calculator | Check your BMI - NHS | Please fill in your details (www.nhs.uk) Please note, we can only accept self-referrals for adults with BMI 25-45kg/m2 . If your BMI is above 45kg/m2 you may need additional support, please consult your GP who will be able to refer you to other options available.

BMI calculator: Click here to find your BMI
 
 

1. First name *

 

2. Surname *

 

3. Address and Postcode *

 

4. Date of birth *

   DD/MM/YYYY 
 
 

5. NHS/ Hospital Number

 

6. Email address

 

7. Do you consent to us contacting you via email?

 

8. Telephone number *

 

9. Name and address of GP *

 

10. Do you consent to us contacting your GP *

 

11. Do you consent to us sharing your contact details with our commercial weight management provider if appropriate? *

 

12. Height *

 

13. Weight *

 

14. BMI (if known)

 

15. Medications

 

16. Please indicate any health concerns you have which may benefit from weight loss (please tick all that apply) *

 

17. Have you attended a weight management service in the last 6 months? *

 

18. Are you currently attending: *

 

19. Do you have an eating disorder? *

 

20. Are you pregnant *

 

21. Have you given birth in the last 6 months?

 

22. How did you hear about our service? *

 

23. Preferred language *

 

24. Do we have your consent to contact you for feedback?
*

 

25. Please type your full name to sign this form: *

 

26. Today's date *

   DD/MM/YYYY