Eat, Move, Be Happy Enrolment

If you are interested in enrolling in any of our programmes, just fill out the form below to sign up.

Email address *

First name *

Last name *

Contact number *

Date of birth *

YYYY

Funding options *

Which GP practice is funding you. If you have not had CONFIRMATION of funding from your GP, choose "Self Funded".

Which service are you interested in? *

For full descriptions of all the services on offer, go to www.EatMoveBeHappy.com

Preferred start date *

From when can you start? We cannot promise this date, but we will do our best to accommodate.

YYYY

Medical conditions or disabilities

Please tick if you have any of the following:

High blood pressure

Cardiovascular disease

Diabetes

High cholesterol

Excess body weight (BMI 30+)

Sensory impairment

Mental health condition

Physical disability

Learning disability

Other:

What do you want to achieve from completing this programme? *

How confident are you at achieving this goal? *

Not confident

Very confident

How confident are you at managing your weight? *

Not confident

Very confident

How confident are you at managing your health and wellbeing? *

Not confident

Very confident

How confident are you at managing your exercise and activity? *

Not confident

Very confident

Where did you hear about this programme? *

Disclaimer *

I acknowledge I take part in this programme under my own free will and accept full responsibility. The contents of this programme are for information purposes only and are not a substitute for professional medical advice.

I agree

Required

Send me a copy of my responses.

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