Suite 2/710 Hunter Street 
Newcastle West NSW 2302	 
p. 02 4092 7788
f. 02 4092 7789
e. hello@hunterblood.au

Dr Karan S Makhija, Dr Wojt Janowski, Dr Ritam Prasad, Dr Sam Yuen, and colleagues

Patient Name					DOB			Mobile
Address 

Thank you for reviewing this patient for provision of a zoledronic acid infusion. 
I have discussed indications and side effects with the patient.
I have provided a prescription and dose for zoledronic acid to the patient and instruced them to bring the medication to their appointment.

Zoledronic Acid Dose
Check one: 	☐ 4mg		☐ 5mg		☐ Other	

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. 
Address	 						Date 
Phone			          Fax			E-mail