Zoledronic Acid Infusion e-Referral

To Dr Karan S Makhija, Dr Wojt Janowski, Dr Ritam Prasad, Dr Sam Yuen

Thank you for reviewing this patient for provision of zoledronic acid infusion (Aclasta or Zometa)

Patient First Name

Patient Last Name

Patient Phone No.

D.O.B

Patient E-mail

Patient Address

Does your patient have a history of poor venous access

YesNo

Prescribed dose (Please provide your patient with a prescription and instruct them to bring the solution on the day of their infusion) *

4mg5mg

Other dose

Comments Please include latest Creatinine, eGFR and corrected calcium. If not done in last 30 days, please provide patient with a pathology request form to perform prior to infusion

Referring Doctor

Name *

Provider No. *

Date *

Phone

Fax no.

Referrer's E-mailA copy of this referral will be sent here

Address