Test Request Form

Edward J. Fudman, M.D. 1301 W. 38th Street, Suite 702 Austin, Texas 78705 (512) 451-4994

Please print this page for your physician.

BONE DENSITOMETRY REQUEST

Edward J. Fudman, M.D.
Seton Medical Park Tower, Suite 702
1301 W. 38th Street
Austin, Texas 78705
Phone (512) 451-4994 · Fax (512) 452-6155
www.bonedensity.com

!referra.gif (2515 bytes)

Patient's name __________________________ Date _____________

Indication for bone densitometry ___________________________

Referring physician ________________________________________

Appointment date and time ________________________________

Insurance authorization, if required:

Plan ________________________ Auth. No. _____________________

Instructions to patients: Please avoid wearing clothing with buttons, snaps, or zippers from the waist down. Gowns are available if necessary.