Language
English (US)
Loloma Foundation Surgical Request Form
Please fill out information to be considered for possible surgery by one of our 2024 surgery teams. This does not guarantee you a booking. You must complete this form as a first step. We will contact you in early 2024 with further instructions. All surgeries will be performed on Taveuni Island during April/May 2024.
Name
*
Given Name
Surname
Birth Date
*
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Day
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1920
Year
Gender
Please Select
Male
Female
Fiji Health #
Phone
*
Alternate Phone
*
Phone of Relative or Friend
Email
Village
*
Surgical Condition
*
What do you need surgery for?
Photo of your condition
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Have you been seen by Ministry of Health
*
Please Select
Yes
No
What was diagnosis?
*
If "none" , enter "none"
Previous Surgeries
*
List all previous surgeries, If "none" , enter "none"
Health Conditions (check all that apply)
*
High Blood Pressure
High Blood Sugar (Diabetes)
Heart Disease
Lung Disease
None
Other
Current Medications
*
List all Medications, If "none" , enter "none"
Other Information
Submit
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