Bariatric Surgery Enquiry Tool

IF YOU ALREADY HAVE A GP REFERRAL - YOU DO NOT NEED TO COMPLETE THIS SCREENING TOOL.

PLEASE CALL (07) 3153-6633 TO REQUEST FOR AN APPOINTMENT TO SEE DR WONG AND SEND THE REFERRAL TO admin@brisbanegosurgery.com.au

First Name *

Last Name *

Date of Birth *

Age *

Contact Number *

Locality of Residence *

Email Address *

Current weight (kilograms) *

Current Height (in metres) *Enter height in metres (NOT cm)

BMI

How did you find out about us? *

Do you have any of the following conditions? *

Type 2 DiabetesHigh Blood PressureSleep ApnoeaHigh CholesterolFatty Liver DiseaseJoint PainsOther condition related to obesityNone of the above

Details

Have you had a bariatric procedure before? *

YesNo

What procedure and when?

Do you have private health insurance that covers bariatric surgery?

YesNo

Do you have a waiting period to fulfil for bariatric surgery?

YesNo

What procedure(s) are you most interested in? *

What would you like to enquire about? *

The approximate costs of having bariatric surgery with Dr WongI would like to know more about the surgeries Dr Wong offersI am unsure if bariatric surgery is right for meI would like an appointment with Dr Wong to discuss what is right for me

How would you like to be contacted?

I will call Dr Wong's rooms 3153-6633 to enquire further (please call between 8:30am and 4pm)Please call me back (this will be during office hours)Please email me back

When is the best time to contact you?We will try out best to contact you in this timeframe, although it cannot be guaranteed due to other practice and patient commitments.

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