Weight Management Referral Form

Weight Management Referral Form

  • All weight management referrals are now made through the Weight Management and Complex Obesity Service Single Point of Access (WMCOS SPoA)

    To proceed with your referral please confirm that you are happy that your data may be shared with, and processed by the organisations listed below and that you agree to be considered for and where appropriate, referred on to - any of these services as part of their care:

    Please note that the referral does not guarantee access to a specific weight management treatment, as suitability will be determined through clinical assessment. 

    Referrals are managed through a digitally enabled single point of access, supported by Artificial Intelligence and overseen by a Clinical Nurse Specialist. 

    • East Suffolk and North Essex NHS Foundation Trust 
    • Big Picture Medical Ltd
    • Feel Good Suffolk 
    • Essex Wellbeing Service 
    • NHS National Diabetes Prevention Programme (Xyla Health and Wellbeing) 
    • NHS Type 2 Diabetes to Remission (Counterweight) 
    • NHS Digital Weight Management Service (this could be Slimming World, Second Nature, Xyla Health and Wellbeing, More Life, Oviva, Liva) 
    • Roczen
    • Suffolk GP Federation
    • GP Primary Choice Ltd.
    I agree I have been informed that my data may be shared and processed by the organisations listed above and that I am aware that the referral does not guarantee a specific weight management treatment and they are managed digitally, supported by artificial intelligence overseen by a Clinical Nurse Specialist.

  • Are you digitally excluded?

    A patient is considered digitally excluded when they lack the skills, confidence, access, connectivity or functional ability (including disability, language, sensory or cognitive needs, or socio-economic barriers) to safely and effectively use digital components of the Weight Management and Complex Obesity pathway. 

    Please confirm if you would be able to use and access digital components of the Weight Management Service? (Where digital exclusion is identified, the service will apply reasonable adjustments to ensure equitable access)

  • Once the referral has been made you will be sent a welcome video, consent and contact form and a patient health questionnaire.

    The patient health questionnaire must be completed prior to acceptance into the ESNEFT Complex Obesity Service. The questionnaire will be sent by e-mail and a letter will also be sent with details to complete this online or request a paper questionnaire. 

    Please confirm that you understand if you do not complete the Patient Health Questionnaire within 3 months of issue, your referral will not proceed and you will be discharged from the service.

  • Patient Details

    Please complete the below patient details. 

    Gender:
    Preferred method of contact:

  • History of previous participation in weight management services

    Please state yes or no to all relevant services that have previously been offered to the patient. 

    Tier 2 Weight Management Service/Community Weight Management Programme - such as Feel Good Suffolk/Slimming World/ Nutrition & Exercise Advice / Group Sessions (optional)
    Tier 3 Specialist Weight Management Service (optional)
    Tier 4 Specialist Weight Management Service/ESNEFT Complex Obesity Service (optional)
    NHS Digital Weight Management Programme (DWMP) (optional)
    NHS Diabetes Prevention Programme (DPP) (optional)
    NHS Type 2 Diabetes Path to Remission Programme (T2DR) (optional)

  • Obesity related complications: Exclusion criteria

    Please complete the following. 

    Pregnant
    Suicide attempt in last year
    Diagnosed eating disorder/no previous interventions in eating disorder service
    Uncontrolled Mental Health - experienced a mental health crisis in last year
    Self harm within the last year
    Had bariatric surgery within the last year

  • Patient Clinical Details

    Have you had your blood pressure taken at the surgery or pharmacy within the last month? (If no, we will contact you to arrange an appointment for you to use our kiosk at the practice to provide this) (optional)
    Recreational drug use (optional)

  • Obesity related complications

    Pre diabetes (optional)
    Type 2 Diabetes (optional)
    Peripheral Vascular Disease (optional)
    MASLD (Metabolic Dysfunction-Associated Steatotic Liver Disease) (optional)
    MASH (Metabolic Dysfunction-Associated Steatohepatitis) - was NASH (optional)
    Cirrhosis - Non Alcoholic (optional)
    CKD - Chronic Kidney Disease (optional)
    Hypertension (optional)
    Hyperlipidemia (optional)
    Stage 1a Endometrial Cancer (optional)
    Atypical Endometrial Hyperplasia (optional)
    Obstructive sleep apnoea (optional)
    Obesity Hypoventilation Syndrome (optional)
    Polycystic Ovary Syndrome (optional)
    Asthma (optional)
    Gastro-oesophageal Reflux Disease (optional)
    Previous Myocardial Infarction (optional)
    Lymphoedema (optional)
    Ischaemic Heart Disease (optional)
    Osteoarthritis (optional)
    Atrial Fibrillation (optional)
    Idiopathic Intracranial Hypertension (optional)
    Heart Failure (optional)
    Abdominal Wall Failure/Hernia - unable to operate due to BMI (optional)
    Previous CVA/Stroke (optional)
    Precluded from other surgery due to BMI > 35 (optional)

  • Other Medical Information

    Hypothyroidism (clinical or sub-clinical) (optional)
    Known Gallstones - symptomatic (optional)
    Known Gallstones - Asymptomatic (optional)
    Previous Pancreatitis (optional)
    Multiple Endocrine Neoplasia, Type 2 (MEN Type 2) (optional)
    Medullary Thyroid Carcinoma (optional)
    Family history of Medullary Thyroid Carcinoma (optional)
    Family history of multiple Endocrine Neoplasia (optional)
    Type 1 Diabetes Mellitus (optional)

  • You have now reached the end of this form. Thank you for completing.

    Your answers will be reviewed and if required we will be in touch with you with regards to this form. 

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Page last reviewed: 25 March 2026