REFERRAL PADS

Patient Information

Patient Surname :

Given Name :

Address :

Appointment Details

Appointment Date/Time :

Results/enquiries Phone Number :

Email :

Medical Information

Pregnant :
YesNo

Test Requested :
BMD by DXAVertebral Fracture Assessment (VFA)Whole Body Composition Scan

Referring Doctor

Referring Doctor :

Results Method :
EmailHardcopy

Email :

Provider Number :

Copy to... Address :

Medicare Rebatable Conditions (One scan per 12 months)

Medicare Conditions - 12 months :
Oral/Inhaled steroids >3 months / Cushing's syndromeFemale hypogonadismAmenorrhoea >6 months & <45 yrs oldMale hypogonadism

Medicare Rebatable Conditions (One scan per 24 months)

Medicare Conditions - 24 months :
Thyroxine excess and/or HyperthyroidismMalabsorption (incl. Vit. D deficiency)Fracture following minimal traumaRheumatoid arthritis (OA not rebatable)Primary HyperparathyroidismChronic liver/kidney disease

Conditions for those over 70 years of age

Conditions for over 70 :
Not previously scannedPrevious T-Score above -1.5 (eligible every 5 yrs)Previous T-Score between -1.5 and -2.5 (every 2 yrs)