Healthy Weight For Life Program Application
IMPORTANT: This program has been designed to assist you and your healthcare team, optimally manage your type 2
diabetes. It does not replace the advice given by your own healthcare professional or medical practitioner. Please
consult your GP before commencing this program and attend regular checkups to keep them updated with your
progress.
With calorie (or kilojoule) restriction, increased physical activity and weight loss you may experience substantial
improvements in your blood glucose control, blood pressure or cholesterol. As your measurements change your GP
may need to make adjustments to the dosage of some of your medication. Please consult your GP before making any
adjustments to your medication. For specific advice on how best to manage your diabetes please consult your GP,
diabetes specialist or Accredited Practising Dietitian.
IMPORTANT: Some internet email servers have been known to block
automated email deliveries. If you do not receive an email confirming your
application within the next 45 minutes, please send an email to
hwfl@hwfl.com.au 1800 226 180 and we will send it to you personally.
In order to be able to participate in the Healthy Weight For Life program,
you must read, understand and agree to the following statements, and indicate
so by checking each statement.
You will then be asked to enter your personal details, and fill out the baseline
health survey.
Once you have completed the online application, a confirmation e-mail will be
sent to your nominated e-mail address. Attached to this e-mail will be the
“Application and GP Approval Form”, you will need to print out this form, fill
in your details and take it to your GP. Once your doctor gives their approval for you to
participate then you need to fax the form back to HCF who will then activate your account.
YOUR SAFETY
Yes, I have viewed and understood the following presentations on the Healthy Weight For Life
homepage and now wish to enrol in the Healthy Weight For Life program.
I understand that KicStart™ contains lactose, ingredients from milk, fish products, cereals
containing gluten, and soy products. It may contain traces of egg, peanuts, tree nuts, sesame
or crustaceans. I am not allergic or intolerant to the ingredients of KicStart™ VLCD.
(Members who are allergic or intolerant to any of the ingredients in KicStart™ should
not participate in this pilot.)
For more information on KicStart™ VLCD please refer to the KicStart™ VLCD presentation.
I understand that KicStart™ may be unsuitable for use by pregnant, nursing or lactating
women, or by infants, children, adolescents or the elderly. I am not pregnant or breastfeeding,
nor intending to become pregnant during the next 18 weeks.
I understand people with gout, gall bladder, heart, kidney, or liver problems, or are aged over
65 should be carefully assessed by their GP or medical specialist to determine if the Healthy
Weight For Life program is suitable for them. If enrolled, regular supervision by a GP is then
required.
I have read and understood the "IMPORTANT" statement on the top of the page and I
understand that if I am being treated for diabetes, high blood pressure or cholesterol, or if I am
on lithium therapy, it is particularly important that my doctor maintains close supervision and
monitors my medication carefully whilst I am on a weight loss program (including the Healthy
Weight For Life program). I will not stop or reduce my medications without my doctor's prior
approval.
YOUR ELIGIBILITY
I have held an HCF hospital product for at least 12 months.
I am 18 years or older and I have medically diagnosed type 2 diabetes and a body mass index (BMI) of 30 or greater.
I have regular internet access and a personal email address to receive follow up information
and reminders.
I am willing and able to regularly visit the personal online record page to record my
measurements and view the on-line coaching sessions.
YOUR MOTIVATION
I am motivated to follow the structure of the Healthy Weight For Life program.
I am motivated to complete the full 18 week Healthy Weight For Life program.
YOUR PRIVACY
Note: For more details, see the presentaion on Privacy .
I give my approval for my ANONYMOUS (de-identified) health information to be sent to HCF
so they can assess the effectiveness of the program.
I understand that Prima Health Solutions Pty Ltd will be co-ordinating the Healthy Weight
For Life program and during the program will need to collect information on my:
age
height
weight
waist circumference
blood pressure
cholesterol levels (total, HDL and LDL)
triglycerides
HbA1c
health status
I understand that Prima Health Solutions Pty Ltd will ONLY use my
information for the purposes of running and assessing the Healthy Weight
For Life program. I understand that if I am also enrolled in the My
Health Guardian program, run by Healthways Australia on behalf of HCF,
Prima Health Solutions will inform My Health Guardian of my enrolment
status and progress on the Healthy Weight For Life program so as to
update my personal profile on My Health Guardian.
Additional Help, Information, Support
For additional help, information or support please don't hesitate to contact
the Healthy Weight For Life team at any time on
Phone: 1800 226 180 (free call)hwfl@hwfl.com.au www.kicstart.com.au
Complaints or Concerns
If you have a complaint or concern about any aspect of the Healthy Weight For
Life Program please don’t hesitate to contact Luke Lawler, Prima Health
Solutions Pty Ltd Scientific Director directly, on
Phone: 1800 226 180 (free call)hwfl@primahealth.com.au
Or the Medical Director, HCF of Australia Limited:
C/- Janice Isaacsjisaacs@hcf.com.au
