New Leaf Weight Loss Solutions

Please fill in this form with as much detail as possible. It will be sent to Dr Hruby who will assess it and we will then get back to you if we need more information or if we need to speak with you personally. If he has sufficient information he will approve you and we will send you a quote and a date and ask if you would like to go ahead for surgery. It usually takes up to 5 working days for us to get back to you. If you do not hear from us please contact me on info@newleafwls.co.uk or ring Amanda on 07551958653

Mobile for out

Name

First

Last

Email

Date of birth

Age

Sex at birth

Male
Female

Occupation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile phone and whatsapp number

Medical and lifestyle information

Please provide as much detail as possible. Our surgeon does not have access to your medical records so it is important that he gets as much information here as possible.

Height

Weight

BMI

Your highest BMI and date

Are you currently under medical investigation or being treated for any medical problems. If so, please give more details

Yes
No

Please provide more information

Important medical information (check all that apply)

Please give details of all medication

Lifestyle information (check all that apply)

I eat large portions
I eat a lot of sweet foods
I find it difficult to stop when I am no longer hungry
I intake a lot of liquid calories (alcohol , sweet drinks, flavoured coffees)
I often go back for seconds
I dont eat much during the day but binge in the evening

Preferred type of procedure (if surgeon agrees)

Have you previously had bariatric surgery

Yes
No

If so, what type of surgery, when and which surgeon

Preferred date of surgery

Patients arrive on a Monday for consultations and tests with surgery being performed either Tuesday or Wednesday. Please indicate 3 surgery dates that you would prefer and we will do our best to accommodate your wishes.

First choice

Second choice

Third choice

Next of kin

We will only use this information in an emergency

Name of next of kin

First

Last

Telephone number of next of kin

Section Divider

All prices are for a shared room with one other person and a shared bathroom. Would you prefer a private room at an additional cost of ¢300

yes
no

Please tell us how you found out about New Leaf

Cross Border Directive

Patients from other EU countries can claim the cost of their surgery back through the Cross Border Directive scheme.

We can help facilitate this for you. There will be a non refundable consultation charge of 200 euro for our support in helping you apply for this directive which includes assistance with submitting forms, receipts etc. Although the majority of claims submitted have been successful we cannot guarantee any outcome or that you will receive any or all monies reimbursed:

Will you be claiming through the CBD

Yes
No

Please upload a full length photo of you fully clothed if you cannot upload, please email to info@newleafwls.co.uk

Drag & Drop Files, Choose Files to Upload

Thank you for submitting your form

We do our best to get back to you with a result or a request for further information within 5 working days. If you do not hear from us please contact Amanda at info@newleafwls.co.uk or on 00447551958653

With love

Amanda x