New Patient Application New Patient New patient request information Have you watched the presentation or read the information on the homepage?(Required) Yes No If not, please do - it's good stuff.Have you read the Aionhealth Frequently Asked Questions?(Required) I have read and understood the information presented on the FAQs page.If not, please do, as an understanding of the information covered there is legally required to proceed.Do you agree to read the information sheets detailing the potential side effects that will be sent along with any prescriptions? (also available on the Resources page)(Required) Yes No Important: prescriptions provided by this service will only be able to be filled at Australian pharmacies.Name.(Required) Personal/Given. Family. This will be used on any prescriptions provided.Best Contact Telephone Number.ePrescriptions will be sent to this number if requested.Medicare Number. Allows us to send ePrescriptions.Email.(Required) Enter Email Confirm Email This will be used along with Name and Date of Birth to confirm the identity of returning patients.Address.(Required) Street Address Address Line 2 City State / Territory Post Code Height.(Required) Current Weight.(Required) If unsure please weigh yourself as we are unable to proceed without this information. If you don't want to know, consider getting someone else to check the scales and enter the information.Highest ever weight. Goal weight. Ethnic background (optional). Different target weights can apply.Essential information.Date of birth.(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you previously tried dieting?(Required) Yes No How successful has your dieting experience been?Are you Diabetic? (to assess for potential qualification for PBS medication cost subsidy) Yes No Are you currently on insulin therapy? (doses may require alteration as weight decreases) Yes No What was your most recent HbA1c%? (a blood test done either to diagnose Diabetes, or done every 3-4 months to monitor adequacy of Diabetes control) Used to assess for potential qualification for PBS medication cost subsidy. If unknown, but you think you’ve been tested for diabetes in the last few years, please enter pathology company the test was done with. Are you able to get pregnant?(Required) Yes No Are you currently, or soon likely to be trying to get, pregnant? Yes No Are you currently breastfeeding?(Required) Yes No Do you get Migraines? (to assess for potential qualification for PBS medication cost subsidy) Yes No Do you have a diagnosis of Epilepsy? (to assess for potential qualification for PBS medication cost subsidy) Yes No Do you have Multiple Endocrine Neoplasia Type II? (If you don't know what this is - say No)(Required) Yes No Do any of your close relatives have Multiple Endocrine Neoplasia Type II? (If you don't know what this is - say No)(Required) Yes No Have you ever had any kind of weight loss surgery?(Required) Yes No What was the procedure? If you have had more than one procedure, please list them all.When was it done?Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920List the most recent major bariatric surgery, if more than one has been performed.List of all current medications (ideally with doses and frequency. e.g., Paracetamol 1g three times a day, etc).(Required)State "None" if not currently on any medications.List of all current supplements (vitamins, minerals, herbal, other).Other relevant issues (e.g., amputee - would change weight implications) or anything else you think we should know.Regular GP's name and suburb?(Required) A letter detailing your treatment plan will be sent to your regular treating GP.Referral Did this or any other doctor refer or recommend you to us? Who? If so, we will try to get a formal referral so part of the fee can be charged to Medicare. Are there any other doctors you would like notified? Would you prefer paper prescriptions (posted) or ePrescriptions (sent by SMS)?(Required) Paper Prescription (posted) ePrescription (sent via SMS) Important: prescriptions provided by this service will only be able to be filled at Australian pharmacies.Optional InformationDo you suffer from troublesome back pain? Yes No Additional Information Do you suffer from Hip or Knee Osteoarthritis? Yes No Additional Information Have you been diagnosed with Cirrhosis of the Liver? Yes No Additional Information Have you been diagnosed with Fatty Liver (NAFLD or MASLD)? Yes No Additional Information Have you been diagnosed with any degree of Kidney failure? Yes No Additional Information Are you currently seeing a physiotherapist, exercise physiologist, or personal trainer regularly? Yes No Are there any other conditions or issues you think we should know about?Current self-photo (Optional) Drop files here or Select files Max. file size: 100 MB, Max. files: 3. Anything other attachments you wish to share - photos, medical documents, etc. Drop files here or Select files Max. file size: 100 MB, Max. files: 6. Consent(Required) I agree to the privacy policy.New patient evaluation: Price: After review for suitability you will be contacted for the balance of $359 before receiving your customised plan.Credit Card Untitled Δ
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