Tier 3 Weight Management Service Referral Form

Please complete ALL the sections and return the completed form by email to or by post to:
Tier 3 Weight Management Service, Walton Hospital, Chesterfield S40 3HW
Referrals will only be accepted from Derbyshire GP’s and Specialist Physicians*
For more information telephone 01246 515166
*Referrals from Specialist Physicians must be copied to patient’s GP with a request to send a list of co morbidities and medications to the Tier 3 service
Section 1 - Client Details
Title / Full Name / NHS No.
D.O.B / Gender / Female  Male  Transgender 
Address / Postcode
Email address / Homephone
Mobile
phone / Consent to leave voicemail? / Yes No 
Best time to contact client / AM  PM 
GP Name / GP Surgery Address (or practice stamp)
Does the client need any reasonable adjustments making in order to access this programme e.g. disability access, information & communication needs, or in terms of culture, religion, sexuality or gender? / No  Yes If yes, please state the
nature of support required.
Section 2 – Referral Criteria Please tick the appropriate boxes
BMI 50 or above / Ready, willing and able to undertake lifestyle change to lose weight / 
BMI 35 to 49
(Note: BMI thresholds can be reduced by 2.5kg/m2 for people who are black African, African-Caribbean, Chinese or Asian) / Ready, willing and able to undertake lifestyle change to lose weight.
Has completed a Tier 2 weight management intervention.
Has one or more of the followingcomorbities:
Cardiovascular disease  / Diabetes  / Pre-Diabetes 
Mental ill health related to obesity  / Osteoarthritis  / Intracranial hypertension 
Sleep apnoea  / Fatty liver disease  / Chronic Kidney Disease 
Polycystic Ovarian Syndrome  / Chronic Obstructive Pulmonary Disease 
Clients for whom surgery is dependent on
weight loss  / Other co-morbidities that would be reversed by bariatric surgery. (Please provide justification for the referral) 
/ 
Is this person considering bariatric surgery? No  Yes *If yes they must be a non-smoker,be drinking
within recommended limits of alcohol and have
had stable mental health for the last 12 months
Section 3 – Health Data
Current Use
Weight (kg) / Height (m) / BMI / Blood
Pressure / Smoking / Alcohol
Per week / Units per week
Please tick if the client has any of the following:
Physical Disability / Learning Disability 
Mild mental health condition 
Enduring mental health condition 
Other conditions, please give details
Pleasegive details of medication, or attach current prescription, and latest results of blood tests.
(Please note- for referrals from specialist physicians to be processed, they must be copied to the patients GP with a request to send a list of comorbidities and medication to Tier 3.)
Section 4 - Other agencies involved in care & any risk issues
Are there any other services involved in this person’s care? / Yes  No 
If yes please provide contact details for each service
Please highlight any risk/safety issues we need to be aware of including recent history of verbal &/or physical aggression towards others or inappropriate, anti-social behaviour/substance misuse
Section 5 – Consent and Referrer’s Details:
(All referrals must be signed by GP or specialist physician)
I confirm this person is suitablefor the programme, is over 18, and is registered with a Derbyshire / Derby City GP(excluding Glossop) / Yes  / I confirm that I have discussed the service with the client, they have agreed consent to be contacted by the Tier 3 Weight Management Service, and are motivated to lose weight / Yes 
Name / Position
Place of Work / Telephone number
Signature / Date
This information will be treated as private and confidential and will be collected bytheTier 3 Weight Management Service for the delivery of lifestyle interventions. This information will be held by the Tier 3 Weight Management Service and processed in accordance with the Data Protection Act 1998. This information will only be shared with services that the patient has consented to share with.

Version: March 2018