Congratulations on making your first step towards A New Life. This is a medical assessment form, the information will be provided to the Bariatric Surgeon for adecision on whether you qualify for this type of surgery. This form takes about 10-15 minutes to complete, so grab a cuppa and get started! After submitting, we should have a decision back within 24-48 hours.

What you will need

  • 15 minutes spare
  • 2 recent photos of you (1 side on, one front on – head to toe. (clothes on)
  • A recent photo of your face
  • Your medical history (no documents, just information)

If you have any concerns about completing the form, please submit a consultation
request and we will call you to complete the survey over the phone.

Full Name (as per passport if you have one) *

If you do not have a passport at this time, your name as shown on your drivers licence

Date of birth *

We hate having to type the email twice too, but it is very common to mistype an email!

More about you

We need to collect information about you to provide an accurate view to the Bariatric Specialist who will assess your eligibility.

If you identify as other, please specify below which sex you identify with. This is important for BMI calculations

About your weight and body

Discussing your weight can be difficult. Some questions may require you face some of your inner 'demons' and personal challenges. Please be as honest as possible when answering.

This photo will not be shared with anyone else other than the surgeon and supporting medical staff
This photo will not be shared with anyone else other than the surgeon and supporting medical staff
This photo will be provided to medical staff and ground customer service staff as part of your profile pack.
This data forms part of your BMI Calculation
It is important you answer this question honestly as it forms part of your BMI calculation
Required for BMI calculations
You can answer this even if your weight has fluctuated +/- 10kg over time.
Enter a year or your age when you started putting on weight
This question does not judge. This is to give the surgeon scope to the type of surgery required.
This does not affect eligibility. It assists the dietitian in forming an eating plan
If you work in an office and do not do any exercise you would classify yourself as sedentary.
We provide access to an exercise physiologist who will determine the most appropriate plan for you over the first 84 days.

Smoking & Alcohol

This question may determine whether further tests are required prior to surgery. Please answer honestly.
This question doesn't judge, it is simply required so we can determine whether further tests are required prior to surgery. Please answer honestly.

Your Medical History

We need to collect information about your medical history. It is important you answer accurately and honestly.

Please list all medications including any pain relievers you may take regularly (eg aspirin, panadol etc)

Family medical history/conditions

Mental Health

Let us know in a sentence or two - your motivations are important considerations for approval
Fast Tracked is usually within the next 21 days. We hold open surgery spaces for patients who wish to go as soon as possible. If you select YES, we will provide you both a fast-track and normal quote.
If you do not wish to be Fast-Tracked, you can just enter a preferred month. We will provide you with a range of available surgery dates. If you have indicated 'fast track' we will provide the closest available surgery date.
Select all that apply

Declaration

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