QPC Bone Density Screening Refusal Form

Please complete the fields below and submit.

Bone Density Screening

Refusal Form

Patient Name *

Patient Email *

I have been informed by *

Dr. Rajnikant Patel Dr Narendrakumar Patel Dr Nidhi Karavadia Medical Staff

that it is recommended to perform a bone density scan (DEXA) at least every 2 years. A bone density scan is a low dose x-ray that measures calcium and other minerals in your bones to show the strength and thickness of them. This is used to determine whether a person may have osteoporosis and is used as a screening tool or a tool to monitor the progress of osteoporosis.

I understand that the above has been explained to me and that I have had the chance to ask questions and all my questions have been answered to my satisfaction and that I voluntarily refuse further testing in the form of a bone density scan.

Today's Date *

Patient Signature *

Witness Signature