Weight Management Referral Request

If you wish to be referred to the weight management service, please submit this form.

Height (in Metres):

e.g. 1.75

Weight (in Kilograms):

e.g. 60.6

BMI:

Ethnicity:

Exercise/activity level:

Exercises regularly

Gets little exercise

Gets no exercise

For more information, please visit NHS: Healthy Weight.

Do you consent for referral to weight management services, provided you meet the referral criteria?

Yes

To be eligible for the weight management service, you must meet the following criteria:

I confirm that I meet the referral criteria and I understand that if I do not meet the criteria, my referral request will be rejected.

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