Patient Self-Referral to Nutrition and Dietetic Service

Before filling in this referral form please ensure you have read ‘Guidance for referrals’. Referrals that are filled in incorrectly will be rejected and will delay your appointment.

On receipt, referrals will be prioritised. Clients requiring a home visit will be contacted directly by a clinician.
Clients that can attend a clinic appointment will be invited to contact us to arrange an appointment.
Failure to do so will lead to discharge from our service.

Please ensure all the fields marked* are filled in correctly.


Patient details


GP details

Any medical conditions should be made known in order to ensure appropriate care. Please fill in the medical questionnaire below.
Please tick in response to ALL the conditions/statements listed:*
Do you currently have or have you ever suffered with any of the following, if YES please give details

Please record most recent blood results linked to your conditions (if known):*

If you are referring for advice on high cholesterol, type 2 diabetes or high blood pressure you must include relevant and recent test results to support your referral.