This field is hidden when viewing the formDate DD slash MM slash YYYY Contact DetailsTitle*Full Name*Maiden Name (if applicable)Address* Street Address Address Line 2 Suburb State Postcode Home PhoneWork PhoneMobile PhoneEmail Address* Do you give permission for us to speak with a family member or support person regarding your care? (Optional) Yes No Please provide their name and relationship to you Full name Relationship to you Personal DetailsDate of Birth* DD slash MM slash YYYY Gender*Select..FemaleMaleOtherOther gender*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?* Yes No Medical 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?* Yes No Health Fund Name*Health Fund No.*What level of cover do you have with your Health Fund?*Please check with your Health Fund if you're unsure. Gold Silver Bronze Basic Extras Only Are you seeing us about weight loss (bariatric) surgery?* Yes No Have you had previous weight loss (bariatric) surgery?* Yes No Does your Health Fund cover you for weight loss (bariatric) surgery?*If 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. Yes No Not sure How would you like to fund the costs of weight loss (bariatric) surgery?*You can select one or more options Self-fund Superannuation Not sure Other Pension No.Veteran's Affairs No.Have you been vaccinated against COVID-19?* Yes (double dose) Yes (single dose) No Prefer not to say Basis of ReferralHow did you hear about Sea Change?* GP's recommendation Other specialist's recommendation Google search / our website Facebook Ad in GP's waiting room Previously under care of Dr Gately or Dr McLeod Other online group or feed Word of mouth Other SubmitYour 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.
