Self referral

Name*
First Last
Email*
Phone*
Date of Birth (optional)
MM slash DD slash YYYY
Were you informed of the Logan Healthy Living service through the Logan Endocrine & Diabetes Service (LEADS) waitlist?*
- Yes
- No
GP details (optional)
Practice name, Address, Phone Number, GP Name, Fax no.
Tick the box that best applies to you*
- I have type 2 diabetes
- I have a rising risk of type 2 diabetes
- I have another chronic condition that I would like help managing
- Gym/exercise intervention
Privacy Policy*
Your privacy is important to us. Information you supply will be handled strictly in accordance with our Privacy Policy.
- I have read and accept the conditions outlined in the privacy policy
Date
MM slash DD slash YYYY

Acknowledgement of Country
We acknowledge the traditional custodians of the land on which we operate, the Yuggera, Turrbal, Yugarabul, Jagera and Yugambeh peoples. We pay respect to the Elders, past, present, and emerging, and extend that respect to all Aboriginal and Torres Strait Islander peoples.

A collaborative venture
Logan Healthy Living is a Lifestyle Management Program created by UQ Health Care and funded by the Queensland Government through Health and Wellbeing Queensland. Our success is made possible through the support of participating organisations, including The University of Queensland and Griffith University.

Review Us

Self referral

Self referral

GP details (optional)