Weight Management Registration Form

To register for the LWTC Weight Management Programme, you must be a resident of North Northamptonshire. If you live outside this area, you are not eligible to register for this programme. Please visit your local council website for weight management services available in your area.

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Date of Submission

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Address(Required)

Street Address City/Town County

Postcode(Required)

Best contact number(Required)

Email(Required)

Ethnicity(Required)

Why do I need to provide my ethnicity: As the LWTC Weight Management programme is funded by North Northamptonshire Council, we must abide by strict eligibility criteria to ensure the programme reaches those most in need and suitable for the service. This eligibility criteria is based on your Body Mass Index. With your height and weight, our system will calculate your BMI to confirm your eligibility. We are required to ask for your ethnicity as the eligible BMI figure differs depending on your ethnicity. This is because different ethnicities have a higher chance of developing health problems at a lower BMI. For more information about BMI please visit: https://www.nhs.uk/conditions/obesity/

Main spoken language

Which GP surgery are you registered with?(Required)

Are you registering or being referred following an NHS Health Check?(Required)

Yes

Which measurement system would you like to use?(Required)

Metric (cm / kg)

Imperial (ft/in / lbs)

Metric Measurements

Height (cm)(Required)

Weight (kg)(Required)

Date of weight reading

Imperial Measurements

Height (ft)(Required)

Height (in)(Required)

Weight (st)(Required)

Weight (lbs)(Required)

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Standardised Weight (kg)

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Standardised Height (cm)

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Your Weight

Date of weight reading

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Your Height

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User BMI

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BMI (Hidden from User)

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BMI (Hidden from User)

Confirmation(Required)

By ticking this box, you confirm that you are a resident of North Northamptonshire and are eligible to register for the LWTC Weight Management Programme.