Request

Tele X-ray Screening Service

Doctor’s First Name *

Doctor’s Last Name

E-mail *

Mobile Phone *

Title *

Speciality

Organisation

City

Country

Name of the Patient *

Sex *

Age *

Height (cm)

Weight (Kg)

Risk Factors of the patient

If known, please select the following: Select Multiple Click Ctrl and +

Whether Patient is suffering from secondary causes of osteoporosis

If ‘Yes’, please select the relevant secondary health problems: Select Multiple Click Ctrl and +

Upload Please upload recently taken patient’s digital/ or computed chest X-ray in pdf format