Healthy Weight For Life Program Application

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.

• Healthy Weight For Life Overview
• KicStart™ VLCD
• Safety Information
• Your Privacy

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.