Personal Details

Title*

Name*

Date of Birth*

Residental Address*

Phone Number

Mobile*

Email*

Other

Medicare and Health Fund Details

You are:

Insured

Uninsured

Insurance Health Fund Name

Fund number

Reference

Medicare number*

Reference*

Expiry*

Pension card (if applicable)

Expiry

Health Care card (if applicable)

Expiry

(DVA) VETERAN AFFAIRS card (if applicable)

GOLD

WHITE

ORANGE

DVA Card Number

Medical History

Please tick any conditions you currently have or have previously been diagnosed with

Are you currently pregnant:

Yes

No

Do you currently use a CPAP machine?

Yes

No

Have you previously experienced problems with sedation or anaesthetic?

Yes

No

Other

If 'Other' selected please add more details:

Any complications from surgery or anaesthetic?

History of blood clot (DVT or PE)?

Yes

No

Current Medications

Please list all prescription medications, vitamins, supplements and over-the-counter medications.

Do you take blood thinning medication?

Any Known Allergies:

No Known Medication Allergies

Yes

List all allergies

Weight (kg)

Please enter a number from 0 to 2000.

Height (cm)

Please enter a number from 0 to 300.

What was your highest weight? (kg)

How many years have you struggled with your weight

Please enter a number from 0 to 100.

Have you tried weight loss programs before?

Yes

No

If yes, please specify which ones and the duration

Have you previously undergone any bariatric (weight loss) surgery

Yes

No

If yes, please specify the type of surgery and year

Please list any surgeries you have had in the past, including this year:

Any complications from pervious surgeries?

Yes

No

If yes, please explain

Please list any medications you are currently taking, including over-the-counter drugs, supplements, and vitamins and dosage:

Do you take any blood thinners?

Yes

No

Do you take any weight loss medication?

Yes

No

If yes, please specify:

Lifestyle and Habits: Do you smoke

Yes

No

If yes, how many cigarettes per day?

Do you use nicotine in any other form? (e.g., vaping, cigars)

Yes

No

If yes, please specify:

Do you drink alcohol?

Yes

No

If yes, how often?

Daily

Weekly

Monthly

Rarely

How many caffeinated drinks (coffee, soft drinks, etc) do you consume per day?

Do you have any past or current history of substance use disorder or addiction?

Yes

No

If yes, please explain

Exercise Habits (check all that apply)

None

Light Exercise (e.g., Walking, Stretching)

Moderate Exercise (e.g., jogging, cycling)

Intense Exercise (e.g., running, weightlifting)

Average hours of sleep you get per night?

Please enter a number from 0 to 24.

Do you experience stress or emotional eating

Yes

No

If yes, please explain

Mental Health: Do you have a history of depression or anxiety?

Yes

No

If yes, have you been treated for it?

Yes

No

Treatment type (medications, therapy, etc)

Have you ever been diagnosed with an eating disorder (e.g., binge eating or bulimia)?

Yes

No

Are you currently seeing a psychologist or counsellor?

Yes

No

Do you have a support system in place (friends, family, etc) to help you through your weight loss surgery?

Yes

No

What are your primary reasons for considering bariatric surgery

Improve overall health

Improve quality of life

Manage or eliminate Type 2 Diabetes

Manage or eliminate Sleep Apnea

Have you ever had a consultation with a bariatric surgeon before?

Yes

No

If yes, what was the outcome?

General Practitioner Details

A referral is required to see the specialist.

Name of doctor

Location of medical centre

Phone

Fax

Do you have a referral letter?

Please attach Referral if applicable

Max. file size: 64 MB.

A GP referral is required to see the specialist, please email it before your appointment to office@westvicsurgical.com.au

Other informations

Clinic Booked or Interested in

How Did You Learn About Our Services?

Emergency Contact

Name

Relationship

Contact Number

Privacy and Clinical Record Consent*

I authorise WestVic Surgical to collect, use, store and disclose my personal and health
information as reasonably necessary for my assessment, treatment, surgery, follow-up care,
billing and healthcare administration.

I understand that my medical record may include clinical notes, correspondence,
investigation results, reports and clinical photographs. Relevant information may be shared
with my referring practitioner, general practitioner, hospital and other healthcare providers
involved in my care, or where otherwise required or authorised by law.

I understand that Mr Abbas may use an AI assisted clinical documentation system (AI scribe)
during my consultation to assist with documenting and preparing my clinical notes. I may
decline the use of the AI scribe at any time without affecting my care.

I understand that WestVic Surgical may use a digital consent platform to provide procedure
specific information and to obtain and document my consent. Where required, the digital
consent process must be completed before my procedure can proceed. I may contact
WestVic Surgical with any questions or concerns before my procedure and will have the
opportunity to discuss these with my surgeon before proceeding.

I consent to WestVic Surgical communicating with me by telephone, SMS, email, post,
secure messaging or online forms regarding my care, appointments, forms, fees, billing and
other administrative matters. I will advise WestVic Surgical if I do not wish to be contacted by
a particular method.

Clinical photographs form part of my confidential medical record and will not be used for
advertising, marketing, social media, publication, teaching or research without my separate
consent.

I confirm that the information I provide is accurate to the best of my knowledge and will notify
WestVic Surgical of relevant changes to my contact details, Medicare details, medications,
allergies, health fund status or medical history.

Further information about how WestVic Surgical handles personal and health information,
including access, correction and privacy concerns, is available in the WestVic Surgical
Privacy Policy, which can be obtained from the clinic or accessed via the WestVic Surgical
website.

Note regarding Bariatric Surgery Registry: If you proceed with bariatric surgery, information about the Bariatric Surgery Registry will be provided to you. Participation is voluntary and you may choose not to participate.

Date*

Signature*

New Patient Registration(Bariatric) & Medical History

Bariatric Patient Registration & Medical History

Personal Details

Medicare and Health Fund Details

Medical History

General Practitioner Details

Other informations

Emergency Contact