Suite 14/235 Darby Street 
Cooks Hill 2300	 
p. 02 9190 5380, Opt 1
f. 02 9190 5381 
e. admin@hvhaem.com.au	

Zoledronic Acid Infusion Referral

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

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