Questionnaire & Consent Using Your Own Practitioner

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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 1 of 4 prescribed clinical indicators

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Patient

Name*
Date of Birth*
Please provide you mobile number.

Consent

Consent for DEXA Scan*
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