Please complete the form below and our team will be in touch with you promptly to arrange your complimentary* initial consultation. * Your initial consultation will be bulk-billed at no cost to you. Have you had previous weight loss surgery?* Yes No Because you've had weight loss surgery before, please contact your GP or previous surgeon to discuss whether you are suitable for further weight loss surgery, before requesting a consultation at Sea Change.What is your age (in years)?*Because of your age, please contact your GP to discuss whether you might be suitable for weight loss surgery before requesting a consultation at Sea Change.What is your height (in cm)?*What is your weight (in kgs)?*Your body mass index (BMI)At your current BMI, you are unlikely to be suitable for weight loss surgery. Please see your GP to discuss other options.You are most likely eligible for our Weight Loss Medication Program and/or an Intragastric Balloon (this is a non-surgical procedure). Please complete the following short pre-consultation questionnaire and our staff will be in contact to book your free initial consultation at Sea Change.You may be suitable for weight loss surgery. Please complete the following short pre-consultation questionnaire and our staff will be in contact to book your free initial consultation at Sea Change.You’re highly likely to be suitable for weight loss surgery. Please complete the following short pre-consultation questionnaire and our staff will be in contact to book your free initial consultation at Sea Change.Pre-Consultation QuestionnaireWhich of our specialist doctors would you like to see?* Next available Dr Gately Dr McLeod Your name* First Last Email address* HiddenDate DD slash MM slash YYYY HiddenSource page HiddenPhone number*Phone number* What's the best time for us to try contacting you?*We will do our best to try to contact you at your preferred time, but please understand if that's not possible.Select..8:00-8:59 am9:00-9:59 am10:00-10:59 am11:00-11:59 am12:00-12:59 pm1:00-1:59 pm2:00-2:59 pm3:00-3:59 pm4:00-4:59 pmDo you have a referral from your GP or other specialist?*You do not need a referral to book your consultation. You'll just need one before you attend our clinic for your consultation. Yes No Are you a current or past smoker or vaper?* Current smoker or vaper Ex-smoker or ex-vaper No Do you drink alcohol?* Yes No If yes, approx. how many standard drinks per week?* Do you get acid reflux/heartburn/indigestion?* Yes No If yes, how often and what treatment are you on (if any)?* Medical history*Surgical history*Medications*What weight (kgs) would you like to get down to?*Do you have a preferred procedure or treatment option?* Medication program Balloon Gastric sleeve Gastric bypass I'd like advice Any other comments or questions?Optional
