Menzies Research Institute

17 Liverpool Street, Hobart Tas 7000
Phone: 03 6226 7700     Fax: 03 6226 7704	

Bone Density Request

Name:   	<PtName>	
Address:	<PtStreet>	
Phone: 	(H)	<PtPhoneH>	(M)	<PtPhoneMob>	
Gender:	<PtGender>	Date of Birth:	<PtDOB (long)>	

Indication for Bone Density:  
(Please tick appropriate box)
  	
¨ Aged 70 years and over.	
¨ Confirmation of suspected osteoporosis after low trauma fracture.   		
¨ Monitoring of low bone mineral density (minimum 2 years between scans).	
¨ Prolonged glucocorticoid therapy, excess glucocorticoid secretion, male                          hypergonadism or female hypogonadism lasting 6 months prior to age 45.	
¨ Primary hyperparathyroidism, chronic liver disease, chronic renal disease, 	                  malabsorption, rheumatoid arthritis or thyroid hormone excess. 		
¨ Measurement of bone mineral density following a significant change in therapy.	
¨ Screening test (Not covered by Medicare rebate. A charge will apply).	
	
Referring Doctor	
Doctor’s Name: 	<DrName>	
Provider No:	<DrProviderNo>	Date of Visit:	<Date>	
Practice Details:	<Practice>	
	<Practice:Street>	
Practice Phone: 	<Practice:Phone>	Fax:	<Practice:Fax>	
Email: 	<Practice:Email>	

Professor Graeme Jones
Provider No.  0279276J
LSPN:  003999