Menzies Research Institute

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

Bone Density Request

Name:   	<<Patient Demographics:Full Name>>	
Address:	<<Patient Demographics:Address>>	
Phone: 	(H)	<<Patient Demographics:Phone (Home)>>	(M)	<<Patient Demographics:Phone (Mobile)>>	
Gender:	<<Patient Demographics:Gender>>	Date of Birth:	<<Patient Demographics:DOB (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: 	<<Doctor:Name>>	
Provider No:	<<Doctor:Provider Number>>	Date of Visit:	<<Miscellaneous:Date>>	
Practice Details:	<<Practice:Name>>	
	<<Practice:Address>>	
Practice Phone: 	<<Practice:Phone>>	Fax:	<<Practice:Fax>>	
Email: 	<<Practice:E-mail>>	

Professor Graeme Jones
Provider No.  0279276J
LSPN:  003999