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Who are you referring?
I am referring myself
I am referring someone else
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Please answer the following questions with the details of the person you are submitting the referral for.
Please select one
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I live in Newham
I work for Newham Council
Please confirm your work email address
*
example@example.com
Do you confirm the individual understands that: their personal and medical information is being shared with Xyla Health & Wellbeing so they can participate in the programme, outcome data will be shared securely with their GP, their data will be treated as confidential and held, shared and disposed of in line with all legal requirements (including the Data Protection Act).
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Yes, I confirm the individual understands the above.
Do you confirm that the referee has given verbal consent to be referred?
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Yes, I confirm that the referee has given verbal consent to be referred
Which organisation are you referring from/ what is your relation to the referee?
Please fill the below information for the person you are referring
First name
*
Last name
*
Email
*
example@example.com
How would you like us to call you?
*
Please Select
Mobile
Telephone
Both
Mobile
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Telephone
*
Street address
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Address line 2
City
County
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Post code
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Date of birth (must be over 18 years old)
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-
Day
-
Month
Year
Date Picker Icon
Sex
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Male
Female
Prefer not say
What is your ethnic group?
*
Please Select
Asian or Asian British: Bangladeshi
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Any other Asian background
Black or Black British: African
Black or Black British: Caribbean
Black or Black British: Any other Black background
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
Mixed: Any other mixed background
White: British or Mixed British
White: Irish
White: Any other white background
Other Ethnic Groups: Chinese
Any Other Ethnic Group
Not Known
Prefer not to say
BMI Calculator
Please enter your weight and height measurements:
Please enter your BMI from the calculator above
*
Your BMI is less than 25, meaning you are within the healthy range and are ineligible for this programme.You can now simply close this form.
Your BMI is less than 23, meaning you are within the healthy range and are ineligible for this programme.You can now simply close this form.
Please enter your waist circumference
Have you been pregnant in the last three years?
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Yes
No
Not stated
Are you currently on the National Diabetes Prevention Programm (NDPP) or Low Calorie Diet programme?
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Please Select
Yes
No
Do you have an underlying medical cause for obesity?
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Yes
No
Have you already accessed a Tier 2 weight management service twice in the last year?
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Yes
No
What is your programme choice?
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Weight Management
Physical Activity
No Preference
How did you hear about us?
*
Please Select
Friend/Family
Google
Email
My GP/Healthcare provider
Social media
Workplace
Community information table
Health information booklet
Community outreach
JOY
Other
Is this information you have provided correct?
*
I declare this information is true and correct; if not then I am aware that I could be putting myself at risk by joining this programme.
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