Skip to main content

Weight management referral

Weight Management

Patient Details

Are you completing this form on behalf of:
Please use format DD/MM/YYYY.

BMI

e.g. 1.75
e.g. 60.6
Exercise / Activity level: *

For more information, please visit NHS: Healthy Weight.

Smoking Status:
Do you consent for referral to weight management services, provided you meet the referral criteria? *

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

  • Be over 18
  • Have a BMI over 30 or over 27.5 if you are BAME
  • Have diabetes type 1 or 2 and/or hypertension
*