Wandsworth CCG
DXA REFERRAL FORM
Please note – we are unable to accept referrals for patients under 18 years of age
PATIENT	REFERRER	
NHS Number	~[NHS Number]	Name	~[Free Text:Referring GP Fullname]	
Forename	~[Forename]	GMC/HPC/NMC No	     	
Surname	~[Surname]	Address	~[Surgery Address Line 1]
~[Surgery Address Line 2]
~[Surgery Address Line 3]
~[Surgery Address Line 4]
~[Surgery Address Line 5]	
Address	~[Patient Address Block]
~[Post Code]			
Date of Birth	~[Date Of Birth]	Referring PCT Code	     	
Telephone (Home)	~[Telephone Number]      	Referring Practice Code	     	
Telephone (Work)	     	Telephone No.         
(for urgent clinical findings)	~[Surgery Tel No.]	
Telephone (Mobile)	~[Mobile Phone Number]      	Fax No.	     	
E-mail Address	     	NHS.net mail only	     	
Gender	~[Sex]	Eligible for and does require NHS funded transport?          (car transport only)            Yes 	
Physical/Communication difficulties (specify if any):
     	Wheelchair user?                 Yes 	
If interpreter required, language:      	The patient must be ambulant, or if a wheelchair user they must be able to transfer independently onto the examination couch.	
Ethnicity: ~[Ethnicity]		

Clinical Indication/ Problem         Please indicate which of these risk factors apply to the patient:
	
Recent fracture of wrist, humerus or spine		Long term use of steroids or thyroxine		
Parental hip fracture		Low body mass (less than 19)		
Radiological osteopenia		Coeliac disease		
Inactive Lifestyle		Chronic liver disease		
Smoking		Type 1 diabetes		
High alcohol intake		Rheumatoid arthritis		
Early menopause (<45 years)		Hypoparathyroid / hyperthyroid disease		
Other (please specify): 	

Has the patient previously had a DXA scan?   Yes      No 

If yes, what date was the scan?          /       /      

Notes:
•	A DXA scan should only be repeated every 18 months – 2 years
•	This scan is of limited value in a patient whose weight is over 150kg

Referrer’s Signature ______________________                                        Date of referral ~[Today...]

Please post, fax or e-mail this form to the InHealth Patient Referral Centre:
Sandbrook House, Sandbrook Way, Rochdale OL11 1RY
Tel: 0333 202 0297 Fax: 0333 200 1163 E-mail: inl.inhealthreferrals@nhs.net
	
www.inhealthgroup.com

EMIS LV:  July 2016