Shop 3-5/7-9 Gibbons St, Redfern NSW 2016
Mon - Fri: 9:00am - 5:00pm  |  Sat: 9:00am - 1:00pm
 (02) 8399 5320   (
(02) 8399 5317   Ê
myhealth.net.au/redfern   ý
redfern.reception@myhealth.net.au  *	

Iron Infusion Referral Form	
Patient Name:	<PtFullName>	DOB:	<PtDoB> <==Patient must be 16 years and over==>Age 16+ 	
Patient Address:	<PtStreet> <PtCity> <PtPostcode> <PtState>	Contact no:	<PtPhoneMob>	

Clinical Information <==CLINICAL INFORMATION==>	
Diagnosis:	<Diagnosis:>	Allergies:	<Allergies:> 	
Weight: <Weight:>	Hb: <Hb:>	CREAT: <CREAT:>	eGFR: <eGFR:>	Ferritin: <Ferritin:>	
Medical History:	<Pregnant - please refer to antenatal clinic as iron infusions require CTG monitoring.> Pregnant
(please refer to antenatal clinic as iron infusions require CTG monitoring)	<Fluid Restriction> Fluid Restriction	<Heart Failure> Heart Failure	<Renal Failure> Renal Failure	

Iron Order (Ferinject) <==IRON ORDER (FERINJECT)== - Given in divided doses; Maximum dose of 1g per infusion>	Given in divided doses; Maximum dose of 1g per infusion	
<Ferinject 500mg (1 vial)> Ferinject 500mg (1 vial)
<Ferinject 1g (2 vials)> Ferinject 1g (2 vials)
<Ferinject 1.5g (3 vials)> Ferinject 1.5g (3 vials)
<Ferinject 2g (4 vials)> Ferinject 2g (4 vials)	Dose Calculator for Ferinject	

Wt <70kg	
Wt >70kg	

Hb <100g/L	
1.5g	
2g	

Hb >100g/L	
1g	
1.5g	

Please supply your patient with a prescription for their ferinject
Please ensure oral iron supplementation is ceased 7 days prior to iron infusion
Patients are required to bring their own supply of ferinject to their appointment	

Referring Doctor	
Name:	<DrName>	Provider No:	<DrProviderNo>	
Address:	<DrStreet> <DrCity> <DrPostcode> <DrState>	Phone:	<DrPhone>	
		Email:	<PracEmail>	
Signature:	
	Date:	<TodaysDate>	

Please note that this form is for the administration of therapy only.