Application form – WMC membership

Complete the form below to apply for Weight Management Clinic (WMC) membership to the National Association of Clinical Obesity Services.

Use this form to apply for these membership levels:

Full Membership WMC – $200 (inc GST) per annum

Privacy Policy

The National Association of Clinical Obesity Services (NACOS) is bound by and committed to supporting the Australia Privacy Principles (APPs) set out in the Australian Privacy Act 1998 and the EU General Data Protection Regulation (GDPR). NACOS reserves the right to modify or amend privacy and copyright statements at any time, provided those modifications or amendments comply with applicable laws.

All inquiries in regard to NACOS should be directed to info@nacos.org.au

Terms and conditions

Please ensure you read and understand the membership terms and conditions before applying.

Application form - WMC

1. How would you best describe your service? 1. How would you best describe your service? Public hospital Private hospital General practice Private practice Community health service Other clinical obesity service

2. Please select all service providers directly involved in your service 2. Please select all service providers directly involved in your service General Practitioner Bariatric Surgeon Gastroenterologist Endocrinologist Other Physician Dietitian / Accredited Dietitian Psychologist / Clinical Psychologist Clinical Nurse Consultant or Nurse Practitioner Credentialed Diabetes Educator Registered Nurse Exercise Physiologist Physiotherapist Other

3. Number (based on estimated full time equivalent) of health professionals employed

4. Number of unique patients seen in the last 12 months (estimate)

5. What types of patients do you see in your clinical obesity service/centre? 5. What types of patients do you see in your clinical obesity service/centre? Adults Children & Adolescents With a specific co-morbidity Other

6. Is this based on 6. Is this based on Estimates Data

7. Do you have criteria for referral acceptance? 7. Do you have criteria for referral acceptance? Yes No

8. Please outline your criteria for acceptance

9. Do you have criteria for discharging patients back to their regular GP? 9. Do you have criteria for discharging patients back to their regular GP? Yes No

10. Please outline your discharge criteria

11. What types of services/appointments/education do you provide at your clinical obesity service/centre? 11. What types of services/appointments/education do you provide at your clinical obesity service/centre? Weight-loss surgery Pharmacology Diet replacement products Onsite exercise supervision Tele-health Education programmes Psychological therapies for weight-loss Adolescent Clinic Interdisciplinary care Multi-disciplinary team care Other

12. Please provide details on each of these service. For example, if you run group education, is this for certain patients only? Do you provide basic level education, or do you offer structured health education/support services?

13. Are you currently involved in an obesity network with any other services to improve support to people with or at risk of obesity? 13. Are you currently involved in an obesity network with any other services to improve support to people with or at risk of obesity? Yes No

14. Who do you network with? Please specify

15. If your clinical obesity service/centre does currently network with other obesity services, how do you do this? What support/networking do you provide?

16. Would your service ben interested in collaborating obesity care with other level of clinical obesity services/centres? 16. Would your service ben interested in collaborating obesity care with other level of clinical obesity services/centres? Yes No

17. Would your service be interested in having your contact information visible via our find a service search portal? 17. Would your service be interested in having your contact information visible via our find a service search portal? Yes No

18. Are there any current project(s)/research initiatives occurring within your clinical obesity service/centre? 18. Are there any current project(s)/research initiatives occurring within your clinical obesity service/centre? Yes No

19. Please provide a list of what your obesity service/centre is doing

20. Would your clinical obesity service/centre be willing to share the outcomes of the project/research and any associated policies/procedures/models of care with NACOS? 20. Would your clinical obesity service/centre be willing to share the outcomes of the project/research and any associated policies/procedures/models of care with NACOS? Yes No

21. How can NACOS make your service/centre membership more valuable?

22. Please outline any initiatives/projects you think NACOS should be involved in

23. Please advise the full name of the nominated NACOS member

24. Please provide the email address of the nominated NACOS member

25. Please select the health care profession of the nominated NACOS member 25. Please select the health care profession of the nominated NACOS member General Practitioner Bariatric Surgeon Gastroenterologist Endocrinologist Other Physician Dietitian / Accredited Dietitian Psychologist / Clinical Psychologist Clinical Nurse Consultant or Nurse Practitioner Credentialed Diabetes Educator Registered Nurse Exercise Physiologist Physiotherapist Other

26. NACOS Membership Newsletter and Updates 26. NACOS Membership Newsletter and Updates Yes, keep me up to date with NACOS news No, exclude me from the mailing list

27. I agree to the NACOS terms and conditions and privacy policy 27. I agree to the NACOS terms and conditions and privacy policy Yes, I agree to the NACOS terms and conditions and privacy policy

First name

Last name

Current position

Organisation

Postal Address

City

State

Postcode

Country

Website

General Email Address

Office phone number

Mobile number

Full name of clinical lead

Email address of clinical lead

14 + 6 =

Please note: Your membership application is not valid until you have successfully completed the entire process, and received a success message on screen.