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Patient Referral - Online Form for Physicians

Patient Referral Form

Patients Doctor please fill in the form below.

Note: A DEXA scan is NOT recommended if your patient is:

Immboile
Wheelchair bound
Over 125kg

There are important practical issues in performing a scan, such as difficulties in obtaining correct patient position, and risks associated with patient transfer. Our physicians are happy to discuss management of such patients with you.

Referral Options:*

Bone Density Only

Body Composition Only

Bone Density AND Body Composition

Patient Personal Information

Please enter Patient's personal details below

NHI Number

Southern Cross Number

Patients First name*

Patients Last name*

Patients Address

Patients Phone Number

Patient Email Address

Patient Date of Birth

Day

Month

Year

Gender

Male

Female

Age at Menopause (if applicable)

Patient Medical Information

Please enter Patient's medical details below

Has patient previously visited one of our clinics?

Yes

No

Date of their last visit (if applicable)

Day

Month

Year

Clinical Details (including significant illness)

History of Fracture?

Yes

No

Please indicate the approximate Year of - and Site/s of fracture/s (if applicable)

Is the Patient taking any of these Medications?

Prednisone

MHT

Depo Provera

Aromatase inhibitor

Referring Doctor Information

Please enter relevant details below

Referring Doctor*

Date of Referral

Address of Referring Doctor

Doctors Phone Number*

Doctors Email Address*

Preferred Clinic Location

Privacy Policy

Cookies Policy

We have updated our privacy policy in light of the recent legislative changes.

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