Eligibility Assessment

Doctor360

Eligibility Assessment for Procedure

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.

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

Please enter your mobile phone number without the starting '0'. eg. 4123444332.

Required for BMI calculation purposes.

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.

This question is to assist the surgeon in understanding your full medical profile.

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 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.

Images should be a valid format such as jpeg, .jpg or .png
This photo will not be shared with anyone else other than the surgeon and supporting medical staff.

Images should be a valid format such as jpeg, .jpg or .png
This photo will not be shared with anyone else other than the surgeon and supporting medical staff.

Images should be a valid format such as jpeg, .jpg or .png
This photo will be provided to medical staff and ground customer service staff as part of your profile pack.

Your Activity levels

If you work in an office and do not do any exercise you would classify yourself as sedentary.

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.

IMPORTANT

It is imperative that you disclose any and all medical conditions/treatments that you have had in the past or are currently being treated for or under investigation. A rule of thumb, if the condition or treatment could be found on your medical history, disclose it. If there is a condition/treatment not listed, please select 'other' and provide detail.

This question may determine whether further tests are required prior to surgery. Please answer honestly.

eg. Reactions to the anaesthetic, allergic, respiratory, heart etc.

This is very important to give the surgeon an understanding of potential risks.

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

If you are currently on medications, please list all meds and doses along with the frequency.

Family medical history/conditions

Mental Health

Let us know in a sentence or two - your motivations are important considerations for approval

If you have researched and have a preference or preferences, please select all that apply.

About your Doctor360 journey start

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.

By ticking 'yes' you agree that Doctor360 will provide your details to Access My Super to assist you in releasing your superannuation. A representative from Access My Super will contact you directly to advise you about the process and to help you understand the impacts of releasing Superannuation early. Doctor360 will provide the contact details you determine below to Access My Super. Access My Super is an Australian based company specialising in assisting people with Compassionate Early Release of Superannuation.

Declaration

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