Referral for Zoledronic Acid 5mg infusion 
Fax to: (03) 6173 0429 
Dr Helen Cooley 
Department of Rheumatology
Attention: Emma Bavage	

Referrer Details	Patient Details	
Referring GP: <<Doctor:Name>>	Full name: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	
Practice: <<Practice/Location:Name>>	Date of birth: <<Patient Demographics:DOB>>    Gender: <<Patient Demographics:Gender>>	
Address: <<Doctor:Address Line 1>>, <<Doctor:Address Line 2>>, <<Doctor:City>>, <<Doctor:Postcode>>	Medicare number: <<Patient Demographics:Medicare Number>>	
Phone: <<Practice/Location:Phone>>	Address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>	
Provider number: <<Doctor:Provider Number>>	Phone: (H) <<Patient Demographics:Phone (Home)>> (W) <<Patient Demographics:Phone (Work)>>  (M) <<Patient Demographics:Phone (Mobile)>>	
Date: <<Miscellaneous:Date>>	Best contact number: <<Best contact number>>	

Page 2 includes Health Summary information and instructions for the patient 

Indication for Zoledronic Acid 5mg (PBS approved)   	

	

	

Osteoporosis
(Over the age of 70 with a T-Score of -3 or less)	

	

	

Established osteoporosis 
(Fracture due to minimal trauma)	

	

	

Corticosteroid induced osteoporosis 
(long term corticosteroid use (7.5mg or more) for at least 3 months and a T-Score of -1.5 or less)	

	

	

Symptomatic Paget’s disease 
(Fracture due to minimal trauma)	

	

	

Patient has received Zoledronic Acid in the past	

•		
•	 How many doses: 	

•		
•	 Date of last infusion: 	

Pre-referral checklist 	

Yes			No	

	

	
	Date of test	

Vit D>50 mmol/L (current within 30 days)	

	

	

	
	
Date of test	

eGFR>35m mmol/L	

	

	

	

Pre-existing hypocalcaemia?  	

	

	

	

If yes Corrected?	

	

	

	

Pre-existing other mineral imbalance? (phosphate/other)	

	

	

	

If yes Corrected?	

	

	

	

Information provided and discussed regarding side effects of infusion including post infusion reaction, dental, renal, other fractures	

	

	

	

	

Yes		NR	

Prior dental appointment was considered	

	

	

	

Script for Zoledronic Acid provided to patient	

	

	

Patient instructions to be provided by GP	
•	Patient to pre-hydrate (2 glasses of water), withhold NSAIDs and diuretics (if possible) on the day of infusion
•	Paracetamol recommend post infusion for reactions
•	Patient instructed to continue to maintain calcium and vitamin D levels with diet/supplements 
•	Script for Zoledronic Acid provided, and patient has ben instructed to bring the Zoledronic Acid with them to the appointment	

Health Summary	
Allergies
<<Clinical Details:Allergies/Adverse Reactions>>	
Current Medications
<<Clinical Details:Medication List>>	
Past history:
<<Clinical Details:History List>>	
Pathology Results
<<Summary:Investigation Results (Selected)>>