REFERRAL FORM

Email all Referrals to:    info@sainfusion.com.au
OR Fax to:  (08) 7081 7038

PATIENT DETAILS
	REFERRER DETAILS
	
Name: <PtFullName>
	Doctor Name: <DrName>
	
Address: <PtAddress>
	Provider No.: <DrProviderNo>
	
Date of Birth: <PtDoB>
	Practice: <Practice>
	
Contact Phone: <PtPhoneMob>
	Phone: <UsrPhone>
	
Medicare No: <PtMCNo> - <PtMCLine>
Expiry: <PtMCExpiry>
	Fax: <UsrFax>

A. CLINICAL INDICATION
Please select the clinical indication which the referred patient meets for receiving IV Zoledronic Acid Infusion:		

<Please select the clinical indication which the referred patient meets for receiving IV Zoledronic Acid Infusion:>

B. PATIENT SCREENING
Age: <PtAge>
Note: If patient is less than the age of 18, they must present with a parent or guardian.

Is the patient pregnant? 		[<Is the patient pregnant?>]
Is the patient breastfeeding? 	[<Is the patient breastfeeding?>]

Has the patient had a dental check in the last 6 to 12 months?		[<Has the patient had a dental check in the last 6 to 12 months?>]
Allergies: <Reactions>	

By completing and signing this referral form, I confirm that the referred patient DOES NOT have:

❌ Any acute illnesses at the time of referral	❌ Any issues maintaining hydration

❌ Any history of osteonecrosis of the jaw	❌ Untreated vitamin D deficiency	

❌ Known bisphosphonate hypersensitivity	❌ Any history of hypocalcemia 

❌ Any concern for atypical femur fracture	❌ Any unreviewed dental issues

❌ Any planned invasive dental procedures (eg. extractions, implants, root canals)     

C. MANDATORY CLINICAL CRITERIA
I confirm I have attached pathology results which have been performed within the last 90 days and demonstrate each of the following (please tick each to confirm):

<(TICK TO CONFIRM) Corrected Calcium Level >= 2.20 mmol/L>  Corrected Calcium Level >= 2.20 mmol/L
<(TICK TO CONFIRM) Vit D Level >= 50 nmol/L>  Vit D Level >= 50 nmol/L
<(TICK TO CONFIRM) eGFR >= 35 mL/min>  eGFR >= 35 mL/min
<(TICK TO CONFIRM) Magnesium Level within normal range>  Magnesium Level within normal range
<(TICK TO CONFIRM) No history of unstable and/or fluctuating renal function>  No history of unstable and/or fluctuating renal function

D. TREATMENT HISTORY

Is this the patient's first IV Zoledronic Acid infusion?	[<Is this the patient's first IV Zoledronic Acid infusion?>]
	If the patient has had an IV Zoledronic Acid Infusion before, do you confirm 			that it has been at least 12 months since their last infusion?	[<If the patient has had an IV Zoledronic Acid Infusion before, do you confirm that it has been at least 12 months since their last infusion?>]
Has the patient previously been on Denosumab?	[<Has the patient previously been on Denosumab?>]
	If YES, what was the date of last Denosumab administration? (optimal timing of IV Zoledronic Acid is 6 months after last administration)	    <If YES, what was the date of last Denosumab administration? (optimal timing of IV Zoledronic Acid is 6 months after last administration)>

E. REFERRER CHECKLIST
(please tick each to confirm)

<(TICK TO CONFIRM) I have provided the patient with a script for IV Zoledronic Acid>  I have provided the patient with a script for IV Zoledronic Acid
<(TICK TO CONFIRM) I have attached results of blood tests performed within the last 90 days>  I have attached results of blood tests performed within the last 90 days (including calcium level, vitamin D level, magnesium level and eGFR)
<(TICK TO CONFIRM) I have informed the patient to AVOID any anti-inflammatory & diuretic medications for 24 hours before the Zoledronic Acid Infusion>  I have informed the patient that they MUST AVOID any anti-inflammatory medications and any diuretic medications for 24 hours before and after the IV Zoledronic Acid infusion

REFERRER ACKNOWLEDGEMENT

By signing this referral form, the referrer confirms that they have assessed that it is clinically appropriate for the referred patient to receive IV Zoledronic Acid, all contraindications have been excluded, any abnormalities in calcium, vitamin D and renal function have been corrected prior to referral & all potential side effects and risks of Zoledronic Acid have been explained to the patient.

By signing this referral form, the referrer also fully acknowledges and accepts that investigation of the underlying cause(s) of osteoporosis / bone disease, treatment sequencing, and ongoing management and follow-up after the IV Zoledronic Acid infusion are not the responsibility of SA Infusion Services and remain solely the referrer's responsibility. The referrer accepts that it is their responsibility to advise the patient regarding the plan for calcium supplementation and vitamin D supplementation before and after the IV Zoledronic Acid infusion, as they see clinically appropriate.

GP / Referrer Signature:              ____________________________

Date:  <TodaysDate>

<Ix>