Pre Scan Information

YOUR DETAILS:

Name

Clinic Date & Name

Previous DEXA scan T-scores

Please enter all results if you have had more than one scan

DEXA 1 - Date

DEXA 2 - Date

DEXA 3 - Date

DEXA 4 - Date

DEXA 5 - Date

Femur Neck (Hip) Score

Femur Total Score

Spine - L1 Score

Spine - L2 Score

Spine - L3 Score

Spine - L4 Score

Supplements

Do you take any of the following supplements?
If so, how much per day?

Calcium (mg)

Vitamin D3 (i.u.)

Magnesium (mg)

Vitamin K2 (mg)

Boron (mg)

Zinc (mg)

Personal Information

Age of Menopause

Height

Weight

Ever had a fragility fracture? Yes or No

Has either parent broken a hip? Yes or No

Do you smoke? Yes or No

Do you take oral steroids? Yes or No

Rheumatoid Arthritis? Yes or No

Thyroid Problems? Yes or No

Diabetes? Yes or No

Chronic liver disease? Yes or No

Chronic kidney disease? Yes or No

Crohn's/Coeliac/Colitis? Yes or No

Do you drink > 3 units per week? Yes or No

Have you ever had a REMS/Osteoscan before? Yes or No

Thanks for submitting!

Consent Form

First Name

Last Name

DOB

Mobile Phone

Home Phone

Address

Postcode

GP name / surgery address

Clinic date

Clinic venue

Please read the following statements and declarations carefully before intitialising each (ask a member of Osteoscan UK if you have any queries).

I understand that I will need to undress relevant body areas, as required for a bone health assessment. I have the right to refuse this at any time I choose.

Please intial

I consent to a physical examination by Mr NC Birch FRCS (ORTH) Consultant Spinal Specialist and other clinical members of Osteoscan UK as appropriate. If I am uncomfortable with being examined 1-on-1 I can request a chaperone.

Please intial

I understand that I may be exposed to forms of medical latex within the consultancy rooms of Osteoscan UK and confirm that I have no allergies that would be adversely affected by this. I understand that I should inform the staff of Osteoscan UK if I have any other significant allergies.

Please intial

I understand that I should inform the staff of Osteoscan UK if I have any life-assisting electronic implants (eg, pacemakers, defibrillators)

Please intial

I consent to my personal information held by Osteoscan UK (including details of any relevant medical conditions) being passed to necessary third party associates through both digital and physical means such as mail, email, faxes, e-faxes, telephone calls, text messages and any other secure e- ommunication
channels as appropriate. Third parties may include hospitals and general practices, linked clinicians, insurance companies, legal representatives, employers’ representatives/Occupational Health, schools and other bodies (eg fitness clubs). INFORMATION THAT IS PASSED TO THIRD PARTIES IS EXPRESSLY NOT FOR ANY MARKETING PURPOSES

Please intial

I agree to accept my scan results via a non-encrypted email.

Please intial

I agree that my data (made anonymous) can be used in the future for research purposes (NOT MARKETING)

Please intial

The information I have provided is correct and not intended to mislead. I have read, understood and completed this form in full and have asked any questions that I may have prior to signing. I understand that my GP may be informed of my visit, unless I specifically request otherwise. In exceptional circumstances involving serious illness, a threat to life or similar, Osteoscan UK may decline this request.

By signing this form I am consenting to all examinations provided by Osteoscan UK staff and/or associates.

I accept complete responsibility for all personal/family/business/corporate (delete where appropriate) interactions with any health insurance schemes that I may be using to help pay for part, or all, of my fees and acknowledge that I am responsible for any debt or shortfall if the insurance company does not remunerate the treatment in full or in part. In these circumstances I understand that I shall be liable for any outstanding accounts under my name and will incur the costs of recovering the debit (to include internal administrative and external agency fees) should it be passed to a debit recovery agency.

To be signed by the patient (if the patient is under 16yrs of age, this form is to be signed by a parent or guardian)

Your Signature

Select a date

Thanks for submitting!

Data Protection Consent Form

Under the General Data Protection Regulation 2018, we are required to advise our patients on our Data Protection Policy.

As part of the patient record, this clinic is required to retain information for the purpose of consultation for treatment and recording subsequent treatments. This is collected by way of registration and medical consent forms, correspondence from external practitioners in either paper of electronic format and
imagery in electronic format.

Upon completion of the registration, medical and data protection consent forms, all paper files and information therein may be electronically scanned and stored on computer file for as long as the patient remains a patient of the clinic; and thereafter for a period of 7-10 years. Full descriptions can be found in our company policy and are available on request for reference.

All information provided will be treated as confidential and will not be given to any other person(s)/organisation(s) external to Osteoscan UK without the written consent of the patient concerned.

Information may be held both manually and electronically in files accessible only by staff of the clinic who are directly involved in the treatment, data entry and processing of patent records.

I consent to all details, collected by the completion of the registration form, being retained by Osteoscan UK in accordance with their data
protection policy.

Please intial

I consent to all third party correspondence, received by Osteoscan UK being
retained in accordance with their data protection policy.

Please intial

I consent to Osteoscan UK corresponding with this third party companies (GPs, consultants, therapists, insurance companies etc) as part of my treatment process unless I explicitly request so. In this case, I will fully inform Osteoscan UK of who should not be contacted.

Please intial

To enable Osteoscan UK to maintain accurate and up-to-date records, as necessary with GDPR compliance, I will inform Osteoscan UK with any relevant changes as soon as possible.

Please intial

If I wish to see the full Osteoscan UK privacy policy for reference, or have any other queries relating to my data protection rights, I will contact Kathy McDonough on 07526 778596

Please intial

To be signed by the patient (if the patient is under 16yrs of age, this form is to be signed by a parent or guardian)

Print name

Select a date

Your Signature

Thanks for submitting!

Pre Scan Information

YOUR DETAILS:

Previous DEXA scan T-scores

Please enter all results if you have had more than one scan

Supplements

Do you take any of the following supplements? If so, how much per day?

Personal Information

Consent Form

Please read the following statements and declarations carefully before intitialising each (ask a member of Osteoscan UK if you have any queries).

I understand that I will need to undress relevant body areas, as required for a bone health assessment. I have the right to refuse this at any time I choose.

I consent to a physical examination by Mr NC Birch FRCS (ORTH) Consultant Spinal Specialist and other clinical members of Osteoscan UK as appropriate. If I am uncomfortable with being examined 1-on-1 I can request a chaperone.

I understand that I may be exposed to forms of medical latex within the consultancy rooms of Osteoscan UK and confirm that I have no allergies that would be adversely affected by this. I understand that I should inform the staff of Osteoscan UK if I have any other significant allergies.

I understand that I should inform the staff of Osteoscan UK if I have any life-assisting electronic implants (eg, pacemakers, defibrillators)

I agree to accept my scan results via a non-encrypted email.

I agree that my data (made anonymous) can be used in the future for research purposes (NOT MARKETING)

To be signed by the patient (if the patient is under 16yrs of age, this form is to be signed by a parent or guardian)

Data Protection Consent Form

I consent to all details, collected by the completion of the registration form, being retained by Osteoscan UK in accordance with their data protection policy.

I consent to all third party correspondence, received by Osteoscan UK being retained in accordance with their data protection policy.

I consent to Osteoscan UK corresponding with this third party companies (GPs, consultants, therapists, insurance companies etc) as part of my treatment process unless I explicitly request so. In this case, I will fully inform Osteoscan UK of who should not be contacted.

To enable Osteoscan UK to maintain accurate and up-to-date records, as necessary with GDPR compliance, I will inform Osteoscan UK with any relevant changes as soon as possible.

If I wish to see the full Osteoscan UK privacy policy for reference, or have any other queries relating to my data protection rights, I will contact Kathy McDonough on 07526 778596

To be signed by the patient (if the patient is under 16yrs of age, this form is to be signed by a parent or guardian)

Osteoscan UK Ltd – GDPR Data Consent Form – Aug 2021

Do you take any of the following supplements?
If so, how much per day?

I consent to all details, collected by the completion of the registration form, being retained by Osteoscan UK in accordance with their data
protection policy.

I consent to all third party correspondence, received by Osteoscan UK being
retained in accordance with their data protection policy.