Summary: The response rate to the invitation to the fracture liaison service and reasons for non-response were evaluated in 2,207 fragility fracture patients. Fifty-one percent responded; non-responders were most often not interested (38%) or were hip fracture patients. After 1 year of treatment, 88% was still persistent and 2% had a new fracture. Introduction: To increase the percentage of elderly fracture patients undergoing a dual energy x-ray absorptiometry (DXA) measurement, and to investigate why some patients did not respond to invitation to our fracture liaison service (FLS). Methods: In four Dutch hospitals, fracture patients ?50 years were invited through a written or personal invitation at the surgical outpatient department, for a DXA measurement and visit to our FLS. Patients who did not respond were contacted by telephone. In patients diagnosed with osteoporosis, treatment was started. Patients were contacted every 3 months during 1 year to assess drug persistence and the occurrence of subsequent fractures. Results: Of the 2,207 patients who were invited, 50.6% responded. Most frequent reasons for not responding included: not interested (38%), already screened/under treatment for osteoporosis (15.7%), physically unable to attend the clinic (11.5%), and death (5.2%). Hip fracture patients responded less frequently (29%) while patients with a wrist (60%) or ankle fracture (65.2%) were more likely to visit the clinic. In 337 responding patients, osteoporosis was diagnosed and treatment was initiated. After 12 months of follow-up, 88% of the patients were still persistent with anti-osteoporosis therapy and only 2% suffered a subsequent clinical fracture. Conclusion: In elderly fracture patients, the use of a FLS leads to an increased response rate, a high persistence to drug treatment, and a low rate of subsequent clinical fractures. Additional programs for hip fracture patients are required, as these patients have a low response rate. © International Osteoporosis Foundation and National Osteoporosis Foundation 2013.