Integrated Osteoarthritis Management™ Program Application

YOUR SAFETY

I have viewed and understood the following information and now wish to enrol in the Integrated Osteoarthritis Management™ program.

• Program Overview
• KicStart™ VLCD
• Important 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 Integrated Osteoarthritis Management™ program is suitable for them. If enrolled, regular supervision by a GP is then required.

I have read and understood the IMPORTANT SAFETY INFORMATION and I understand that if I am being treated for diabetes, high blood pressure or cholesterol, or if I am on warfarin, insulin or 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 Integrated Osteoarthritis Management™ program). I will not stop or reduce my medications without my doctor's prior approval.

YOUR ELIGIBILITY

I have X-ray diagnosed osteoarthritis of the knee or hip.

I have a body mass index (BMI) ≥ 30.

In my GP’s clinical opinion I have (either / or):

a) symptoms and disease progression that is likely to necessitate referral to an orthopaedic surgeon in the foreseeable future to be evaluated for a possible joint replacement procedure OR

b) an existing joint replacement that is failing and is at risk of needing further surgery in the foreseeable future

I have a private health insurance hospital policy with a participating health fund that I have held for at least 12 months and that does not exclude joint replacement surgery.

YOUR PRIVACY

I have read and agree with my health fund's privacy statement.

In order to facilitate evaluation of the program I consent to my identifiable body mass index (BMI) and knee or hip outcome questionnaire scores to be shared with my health fund. I also consent to my additional ANONYMOUS (de-identified) health information to be used by Prima Health Solutions and participating health funds to assess and report on the effectiveness of the program. No public document or report will identify any individual participant.

I understand that Prima Health Solutions Pty Ltd will be co-ordinating the Integrated Osteoarthritis Management™ program and will ONLY use my information for the purposes of running and assessing the program. During the program Prima Health Solutions will need to collect information on my

• age and sex
• height, weight and waist circumference
• blood pressure, cholesterol levels (total, HDL and LDL), triglycerides and HbA1c
• health status