Weight Management Referral Form

Last Updated: 30/07/2022

Referral for Weight Management Services

Please complete this form if you would like to be considered for a referral to the Weight Management Service

Name *

Thank you for completing the questionnaire. We will review your notes and either refer you to the service or contact you if we ned any more information

Date of Birth *

Postcode *

Email address *

Telephone Number *

Preferred method of contact *

Do you know your BMI *

Yes No

if yes what is it? *

under 20

20.1-24.9

over 25

Don't know

If you do not know your BMI we recommend booking an appointment with our health care assistant. Would you like us to do this for you? *

Yes No

If your BMI is over 25, you may qualify for a referral to the weight management service. Please tick here if you consent to this referral being made if you are eligible. *

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Weight Management Referral Form

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