Weight Management Referral Request

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

Weight Management

Weight Management

Patient Details

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


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