2026 Loloma Foundation Surgical Request Form
Please fill out information to be considered for possible surgery by one of our 2026 surgery teams. This does not guarantee you a booking. You must complete this form as a first step. We will contact you in early 2026 with further instructions. All surgeries will be performed in Savusavu in May/June of 2026
Name
*
Given Name
Surname
Birth Date
*
Please select a month
January
February
March
April
May
June
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Month
Please select a day
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Day
Please select a year
2025
2024
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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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