First name	<PtFirstName>	Last name	<PtSurname>	
Date of birth	<PtDOB>	Medicare number	<PtMCNo>	
Contact details	Mobile: <PtPhoneMob>	Address	<PtAddress>	
<DrDetails>
Signature: _______________________________________    	Provider Number: <DrProviderNo>
Date: <TodaysDate>	
		Dexa Service 	Required		
☐ AP Spine	☐ Hip	☐ Forearm	☐ Initial Scan	☐ Follow-up Scan	
Medical History / Fractures: ________________________________________________________________________________	
TO ENSURE A REBATE OR BULK BILLING, PLEASE TICK THE ITEM NUMBER WITH CORRECT DESCRIPTOR	
12306  ☐ One or more fractures occurring after minimal trauma (breaking a bone after a fall from standing height or less or breaking a rib from coughing).
12306  ☐ Monitoring proven low bone density (Osteoporosis) from previous DEXA or CT scan with a T score of ≤ -2.5 or less
12306 Eligible for rebate every 24 months

12321  ☐ Measurement of bone density at least 12 months following a significant change in therapy ie. A change in the class of drugs rather than for a change in the dosage regimen for established low bone density.
12321 Eligible for rebate every 12 months	12312  ☐ Commencement of a dosage of inhaled glucocorticoid equivalent to or great than 800 micrograms beclomethasone dipropionate or budesonide per day or
12312  ☐ A supraphysiological glucocorticoid dosage equivalent to or greater than 7.5 mg prednisolone in an adult taken orally per day & anticipated to last for a period of at least 4 months.
12312  ☐ Conditions associated with excess glucocorticoid secretion.
12312  ☐ Male hypogonadism: serum testosterone levels below the age matched normal range.
12312  ☐ Female hypogonadism: female hypogonadism lasting more than 6 months before the age of 45.
12312 Eligible for rebate every 12 months	
12315  ☐ Diagnosed with primary hyperparathyroidism
12315  ☐ Rheumatoid arthritis.
12315  ☐ Chronic liver disease. 
12315  ☐ Chronic kidney disease.
12315  ☐ Proven malabsorptive disorders. This is defined as: Malabsorption of fat, defined as faecal fat estimated at greater than 18mg per 72 hours on a normal fat diet, or diagnosed with bowel disease with presumptive vitamin D malabsorption as indicated by a sub-normal circulating 25-hydroxyvitamin D level.
12315  ☐ Histologically proven Coeliac disease.
12315  ☐ Conditions with associated thyroid excess.
12315 Eligible for rebate every	
12320  ☐ Patient is 70 years of age or over and not previously had bone densitometry
12320  ☐ Patient is 70 years of age or over and the      
T –score for the patient’s bone density at any site is ≥ - 1.5.     
12320 Eligible for rebate every 5 years
	
12322  ☐ Patient is 70 years or over and the T – score for the patient’s bone density at any site is between -1.6 and -2.4.
12322 Eligible for rebate every 24 months