According to Victorian state regulations you are required to have a referral in order to complete a DEXA Body Composition scan.

Please complete the below form and once completed, you will be automatically directed to the booking & payment page.

We look forward to scanning you at Good Life Health Club Fountain Gate  on the 12th March 2019!

Your Details

  • NOTE:
    Any false declaration or failure to fulfill medical obligations may result in you not having a total body composition scan.

    I hereby declare that I have not withheld any relevant information including current medications or made any misleading, ambiguous or untrue statement.

    I agree to answer any further medical related questions that may be considered necessary by MeasureUp and its Doctors.

    I agree to indemnify and hold harmless all personnel, directors, officers, shareholders, agents and staff of MeasureUp against any and all loss, damage, cost, suffering, failure to meet expectations, and scan outcomes and any expense that I or any parties associated with me may suffer that is in any way related to the total body composition scan or failure to perform the services, responsibilities, and duties the company or individual has agreed upon or any other medical service in perpetuity in all jurisdictions. This includes the legal costs, fees and expenses of defending MeasureUp against any claim by any or all parties and/or by any other person and/or as a result of my act/s or omission/s.

    I consent on my own behalf (or that of my child/guardianship subject if declaration being completed by a parent/guardian) to Mobile DEXA Pty Ltd collecting the personal information provided by me and/or my doctor/s in this questionnaire having access to this personal information for the purpose of my body composition scan. I understand that the personal medical information concerning me will be stored in accordance with the National Privacy Principles and the provisions of the Australian Privacy Act. I acknowledge and accept that Mobile DEXA Pty Ltd may securely retain this personal information as part of a record of persons who have participated in body composition scanning for a maximum period of five years (unless there are legal reasons for retaining that information for a longer period), after which the information will be destroyed. I understand that if the details provided by me changes or if I want to access or update the personal information held about me, that I may contact Mobile DEXA Pty Ltd for further information on their privacy policy.

    Full Name Signature
    Are you over 18 years of age?
    Guardian Name Guardian Signature
    Date
 

BMI Information

 

Medical History

 

Verification

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