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: Click here to find your BMI

1. First name *


2. Surname *


3. Address and Postcode *


4. Date of birth *


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 *