Contact DetailsTitle*Full Name*Maiden Name (if applicable)Address* Street Address Address Line 2 Suburb State Postcode Home PhoneWork PhoneMobile PhoneEmail Address* Personal DetailsDate of Birth* Date Format: DD slash MM slash YYYY Height*Weight*OccupationNext of Kin*Next of Kin Phone(s)Next of Kin Relation to You*Do you consent to us discussing your appointments, results and other relevant information with your next of kin?*YesNoMedical DetailsName of GP*GP Address* Street Address Address Line 2 Suburb State Postcode GP Phone*Other Treating Specialist (if any)Other Treating Specialist AddressOther Treating Specialist PhoneMedicare Number (10 digits)*Medicare Ref Number*Are you in a Private Health Fund?*YesNoHealth Fund Name*Health Fund No.*What level of cover do you have with your Health Fund?*GoldSilverBronzeBasicExtras OnlyPlease check with your Health Fund if you're unsure.Are you seeing us about weight loss (bariatric) surgery?*YesNoDoes your Health Fund cover you for weight loss (bariatric) surgery?*YesNoNot sureIf you're not sure, please try to contact your Health Fund to clarify this. You should ask if you're covered for item numbers 31575, 31572 and 31584.How would you like to fund the costs of weight loss (bariatric) surgery?* Self-fund Superannuation Not sure Other You can select one or more optionsPension No.Veteran's Affairs No.Basis of ReferralHow did you hear about Sea Change?*GP's recommendationOther specialist's recommendationGoogle search / our websiteFacebookAd in GP's waiting roomPreviously under care of Dr Gately or Dr McLeodOther online group or feedWord of mouthOtherSubmitYour medical records are confidential, however to provide you with the best possible health care it may be necessary to disclose your medical records to or collect them from other health care professionals. To do so, we require your consent.* I consent to the disclosure of my medical records to, or their collection from, other health professionals involved in my care. I understand I have a right to deny this request and also that I have a right to access my medical information.
