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For referrals to the London Osteoporosis Clinic please complete the online form below; alternatively you can fax or email a referrals.

    Your Name:

    Clinic address:



    1. Patient Name*

    2. Patient Email*

    3. Patient Date of Birth*

    4. Gender*

    5. Patient Weight (kg)*

    6. Patient Height (cm)*

    7. Has patient lost any height from peak adult height?*

    8. Does patient any symptoms; if so how long?*

    9. Any previous Fractures?*

    10. Is there is history of parental Hip Fractures?*

    11. Does the patient Smoke?*

    12. Is Alcohol consumption of 3 or more units/day?*

    13. Is the patient taking Glucocorticoids

    14. What other medications are they taking?*

    15. Does the patient have Rheumatoid Arthritis

    16. Does the patient have any medical condition associated with Secondary osteoporosis
(such as diabetes, osteogenesis imperfecta in adults, hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition, chronic liver disease, inflammatory bowel disease, Coeliac disease, asthma, epilepsy) **

    17. Has the patient had a recent DEXA scan – Please forward the results*