We will call the patient to organise their procedure. You will receive the diagnostic report within 48 hours post procedure.

Metabolism Scan - must be 6YO+ & 10kg+ OR any age but 15kg+
BIS Scan (Medical Body Composition) - must be 17YO+ and no electrical implant
Fasting for test is required for minimum 4 hours prior (see bottom of form for detailed preparation procedure)

Private Health | NDIS | Medicare | DVA Rebates Available

By submitting this form you confirm that you have gained the patients consent to share information via online form and have informed them that we will be in contact with them for booking.

Scans are clinically accurate, safe, radiation free, comfortable and quick. They do not require you to remove clothing or exercise. Our metabolism scan is a breath test using a mask. BI-Spectroscopy involves 2 electrodes on each of your wrists/ankles.

Referring Clinician's Name *

First Name

Last Name

Clinicians Email (This email will not be shared with the patient -Results will be sent to this email) *

Profession *

Dietitian

General Practitioner

Personal Trainer/Nutritionist

Gastroenterologist

Sports Physician

Exercise Physiologist

Endocrinologist

Support Coordinator/LAC/NIISQ/TAC

Paediatrician

Nursing Service

Patient's Name *

First Name

Last Name

Patient Phone Number *

(###)

###

####

Nutrition Diagnostics Service *

Metabolism Scan (QNRG Calorimetry) (6YO+ & 10kg+ OR any age 15kg+)

B.I.S Scan Body Composition Analysis (SECA 525 MBCA) (17YO+)

Tube Specialist Consultation (Dietitian Referral) (NG/NJ/PEG/PEJ/STOMA at all ages)

Metabolic Health Consultation (Dietitian Referral)

EDS/POTS/MCAS Consultation (Dietitian Referral)

Other

If answered 'Other', please specify:

Comprehensive Assessment Procedures

Select only if applicable

Nutrition Status (B.I.S, QNRG Calorimetry, Substrate Analysis)

ED Safety Monitoring (All tests from nutrition status + results are blinded & in context of ED recovery)

Nutrition Prescription (precise nutrient requirements)

Subsidy Eligibility (confirmation indicates a diagnosis has been placed and the patient will access a subsidised price for the procedure)

Diagnosed Malnutrition

Notes:

Thank you! We will be in contact with the patient to organise the procedure.

You will receive the patient’s results within 48 hours post procedure.

if you have any questions or require clinical support, please contact us on info@mntdiagnotics.com.au

Preparation For Scans:

NIL for more than 4 hours before scan: food, caffeine, nicotine, large amounts of water, exercise (ideally no exercise or food for several hours before the scan)

Do not alter your medication regime
Those at risk of HYPOglycaemia/use insulin should not fast
(PEG/NG/Enteral feeding) do not supply feeds for 4 hours prior to scan (if safe to do so)
(Parenteral feeding) continue your regular regime
You are unable to undergo a B.I.S scan with a pacemaker, electrical implant or electrical protheses. Metabolism scans are safe for those with implants.