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Patient enrolment
General information
Email
The email address is not made public. It will only be used if you need to be contacted about your account or for opted-in notifications.
Title
- Select a value -
Mr
Mrs
Ms
Miss
Dr
A/Prof
Prof
Prefer not to say
First name
Last name
Date of birth
Date
Gender
- Select a value -
Female
Male
Mobile number
Region/City
- Select a value -
Auckland
-Devonport
-Waiuku
Bay of Plenty
-Rotorua
-Tauranga
Canterbury
-Akaroa
-Christchurch
-Lyttelton
-Timaru
Gisborne
Hawke’s Bay
-Hastings
-Napier
Manawatu-Wanganui
-Pahiatua
-Palmerston North
-Taihape
-Wanganui
Marlborough
-Blenheim
-Picton
Nelson
Northland
-Kaitaia
-Russell
Otago
-Alexandra
-Dunedin
-Kaitangata
-Oamaru
Southland
-Invercargill
Taranaki
-Hawera
-Kapuni
-New Plymouth
-Stratford
Tasman
Waikato
-Hamilton
-Paeroa
-Te Aroha
-Tokoroa
-Waihi
Wellington
-Lower Hutt
-Masterton
-Porirua
-Upper Hutt
West Coast
-Greymouth
-Hokitika
-Westport
Preferred means of communication
Email
SMS
My doctor has prescribed me a medication for weight loss
No
Yes
How did you learn about the Push On® program?
- None -
Heard it on the radio
Online
Social media
Referred by my doctor
A friend told me about it
Please enter the last four digits of the barcode from your prescribed medication for weight-loss
Doctor's name
Practice name
Would you like to join the Push On Nurse Support?
No
Yes
Measurements
Height
cm
Waist
cm
Hips
cm
Chest
cm
Weight
Starting weight
kg
Goal weight
kg
Goal weight change
kg/week
Starting BMI
Consent
I agree to the
privacy policy
I agree to the
terms of use
Enrol
