Osteoporosis Consultation/ Bone Density (DXA) Referral Form

Thank you for your referral. Please fax all previous DXA reports, labs, and any other records to our office at 919-383-9140 or attach all records below. Once those records are received we will contact the patient to schedule the appointment.

Referring physician offices can now upload patient records when submitting web referrals. Click link on the bottom of the page to upload records and orders.

Referring Physician*
Referring Contact Person*
Referring Contact Phone*
Referring Contact Email*
Patient First Name*
Patient Middle Initial
Patient Last Name*
Patient Phone #*
Patient DOB (mm/dd/yyyy)
Has patient ever had a Bone Density test? No
The patient being referred for... Bone Densitometry
Osteoporosis Consult Only
Click Here To Attach Patient Records
(PDF, DOC/DOCX and JPG file types accepted)

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