Iron Infusion Request Form

For GP or specialist use only

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Patient Details

Full Name

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email Address

Phone Number

Medicare Number

Number next to your name on your Medicare card

Medicare card expiry date

Medibank Private Health Insurance

Requesting Doctor Details

Doctor Type

Doctor Name

First

Last

Clinic Name

Clinic Phone

0400 404 404

Signature

Date

Referral

Full Blood Count, UEC LFTs Iron Studies, B12/folate, CMP 1 – 2 weeks prior to intended infusion. A recent Hemoglobin is essential for accurate dose calculation.

Pathology results: File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Medical History

File Type on

Known Allergies / Sensitivities

Previous Reaction to Iron?

Autoimmune or Inflammatory Conditions?

Current Medications

Please list all current medications below. Oral iron supplements must be stopped at least 24 hours before infusion.

Current Medications