COMPLETE DXA SOLUTIONS
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Contact
REFERRAL FORM
Referral Form
Either fill out the form below or download the form fill it out and send as an attachement.
Option 1 - Download the referral form
Download Referral Form (PDF)
Option 2 - Fill Out the Form Below and Send to Us Directly
PATIENT DETAILS
Surname:
Forename:
Gender:
Male
Female
Other
Address:
Home Number:
Mobile:
Date of Birth:
DXA EXAMINATION
Clinical Information:
Current treatment (if any):
Previous fractures:
Previous DXA:
Yes
No
Date:
Risk Factor
Parental hip fracture
Yes
NO
Details
Corticosteroid use
Yes
NO
Details
History of Fractures
Yes
NO
Details
Low BMI
Yes
NO
Details
Alcohol consumption > 4 units per day
Yes
NO
Details
Rheumatoid Arthritis / MS
Yes
NO
Details
Smoker
Yes
NO
Details
REFERRING DETAILS
Referrer’s Name:
IMC No.:
Date:
Address:
Contact Phone Number:
Email
Doctor’s Signature:
GP DETAILS
GP Name:
Phone:
Email
Same as Referring Details
As Above
Send
N.B. Please ensure that all referrals are fully completed.
