Osteoporosis Bone Health Referral | The Waterside Clinic

Date of Referral

Patient Name

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number

Email

Health Card Number

Referring Physician/NP

Billing Number

Family Physician Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Physician Phone

Physician Fax

Physician Email

Referral for Osteoporosis/Bone Health Program

Bone Health Review

Bone Mineral Density completed within the last year

Bone Mineral Density completed within the last year

If not the baseline BMD, please include all prior in referral for our reference

Blood panel for female patients

Blood panel for female patients

Creatinine, alkaline phosphatase, albumin, insured Vitamin D, 1,25-dihydroxyvitamin D, PTH, and calcium.

Physician/NP Xray lateral

Blood panel for male patients

Blood panel for male patients

Creatinine, alkaline phosphatase, albumin, insured Vitamin D, 1,25-dihydroxyvitamin D, PTH, calcium, free and total testosterone • Celiac testing panel (IgQ [G,A,M], total IgE, CBC, ferritin, antiTTG IgA, antigliadin IgA and IgG) • HLA typing, DQB1*02, DQB1*08 (celiac screening)

Xray of lateral spine

Xray of lateral spine

Rule out compression fractures

Other Testing

Any other relevant testing, by your discretion

E.g. x-rays of recent fractures, hospital notes, etc

Urgency of this Referral

Normal
Urgent
EMERGENT

Osteoporosis Bone Health
Program Referral

Referring Physician/NP

The Waterside Clinic

79 Colborne Street E. Orillia, ON L3V 1T5

Office Hours

705-734-3943

Osteoporosis Bone Health Program Referral

Referring Physician/NP

Osteoporosis Bone Health
Program Referral