DEXA Consent using your Practitioner - Body DEXA Fit

Questionnaire & Consent Using Your Own Practitioner

The purpose of this form is to gather some of your details so we know who you are, to guide you to the mandatory referral slip for a DEXA whole body scan in accordance with Victorian State Regulations, and ensure you are aware of our COVID-19 Safety Plan. lf you have any questions about the information requested please contact us on 0409647886. All information provided will be kept confidential. Your written permission is required to release any information. As you are using a Medical Practitioner or specified Allied Health Professional, you must download and use this referral slip. You need to provide this slip to your practitioner please and the practitioner must use this referral slip for the referral. n.b. Conditions Apply: A GP or specified Allied Health Professional can only refer if they satisfy 4 prescribed clinical indicators

Patient

Name*

Prefix First Last

Date of Birth*

Email*

Mobile*

Please provide you mobile number.

Supplementary DNA test?

Would you like a DNA Test too?*

Would you like to purchase the DNA test to help you make better health, wellness and lifestyle decisions?

Yes
No

If Yes, please select your preferred DNA Test

$179 myDNA Comprehensive Wellness Report gives information on your gene association with weight management, diet considerations and predictive markers in cardiovascular health, vitamin sufficiency and fitness recommendations, click here to download a sample report

Consent

Consent for DEXA Scan*

Agree and Continue

By Checking Agree and Continue, I hereby:
State that the above information is correct to the best of my knowledge.
Provide my personal details and a full medical history so that Dr Janet Macintosh may assess and manage my healthcare and determine suitability for a DEXA Body Composition assessment.
Agree for my medical record to be accessed by staff involved in my clinical care, including Body DEXA Fit for the provision of DEXA Body Composition Assessment.
Accept the additional charge of $40 (Non-Medicare funded) for assessment and referral for DEXA body composition scan. This fee will only be charged if I proceed with the initial DEXA scan booking.
Confirm that there is no chance I mage be pregnnant; Confirm I have not had a barium x-ray, nuclear medicine scan or injection of an X-ray dye in the last week;
Confirm that I have not undergone 4 DEXA Body composition scans in the past 12 months

Date*

Name

This field is for validation purposes and should be left unchanged.