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DEXA ConsentTony Eid2020-05-28T22:52:14+10:00

 

Questionnaire & Consent Form

  • DEXA Questionnaire & Consent Form

  • The purpose of this form is to determine suitability for a DEXA Body Composition assessment for Dr Janet Macintosh to generate a referral for a DEXA whole body scan in accordance with Victorian State Regulations. Dr Janet Macintosh is a Specialist Medical Practitioner who holds a specialist registration with AHPRA in Radiology. 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.

    • Please note there will be a cost of $40 (Non-Medicare funded) for assessment and referral for DEXA body composition scan.
    • You will only be charged if you proceed with the initial DEXA scan booking. This initial referral to Body DEXA fit may be used for up to 4 scans within 12 months, to monitor changes in body composition response to intervention, with subsequent scans at least 8 weeks apart.

    Alternatively, you may elect to use a Medical Practitioner or specified Allied Health Professional. If using a practitioner other than Janet Macintosh, you need to use this online form instead. n.b. Conditions Apply: A GP or specified Allied Health Professional can only refer if they satisfy 4 prescribed clinical indicators, whereas a Specialist Medical Practitioner such as Dr Janet Macintosh is not subject to those restrictive clinical indicators.

  • Patient

  • This field is hidden when viewing the form
    Body Mass Index
  • Please provide you mobile number.
  • Your weight in Kilograms
  • Your height in Centimetres
  • What are your health and lifestyle goals for the future, and provide us with any other relevant information
  • Medical History

  • For example, please let us know if you have back pain or knee injuries
  • For example, please let us know if you have back pain or knee injuries
  • DEXA Scan Eligibility

    The current regulatory condition to the use of DEXA for assessing body composition requires the scan to be justified and approved by the Radiologist or Radiographer in accordance with written guidelines established by the Radiologist.
    We can only provide you a DEXA scan if at least one of the following applies to you – please select the reason(s):
  • 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
  • DD slash MM slash YYYY
  • Supplementary DNA test?

  • Would you like to purchase the DNA test to help you make better health, wellness and lifestyle decisions?
  • This field is for validation purposes and should be left unchanged.

ENQUIRIES

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

CONTACT US

Location:
Shop 2, 76-78 Keilor Rd, Essendon North, VIC, 3041

Phone:
Mobile: 0409-647-886

Hours:
Appointments are available during weekdays and the weekend.

Extended hours are also available by appointment.

To view the times, CLICK HERE

If you cannot find a suitable appointment time, please contact us directly on:
0409-647-886

For group bookings, contact us on:
0409-647-886 or Send Mail

Parking:
Free street parking available in the surrounding area.

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