Weight Management Self-Referral Form

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: https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/

1. First name *


2. Surname *


3. Address and Postcode *


4. Date of birth *


5. NHS/ Hospital Number


6. Email address


7. Telephone number *


8. Name and address of GP *


9. Do you consent to us contacting your GP *


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


11. Height *


12. Weight *


13. BMI (if known)


14. Medications


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


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


17. Are you currently attending: *


18. Have you been diagnosed with an eating disorder? *


19. Are you pregnant *


20. How did you hear about our service? *


21. Preferred language *


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


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


24. Today's date *