IRON INFUSION REFERRAL FORM
AMBULATORY CARE CENTRE (ACC)
ROYAL HOBART HOSPITAL
PHONE: 6166 8065
FAX: 6173 0270	Patient Details      		
	SURNAME: <PtSurname>	D.O.B: <PtDoB>	
	OTHER NAMES: <PtFirstName> <PtMidName>	SEX: <PtSex>	
	ADDRESS: <PtAddress>		
	PHONE: (h) <PtPhoneH>  (m) <PtPhoneMob>		

ATTENTION: Dr Helen Cooley
Director Ambulatory Care Centre

Procedure: Iron Infusion – Ferric Carboxymaltose (Ferinject)	
Diagnosis: Iron Deficiency	
PBS Script for Ferric Carboxymaltose (Ferinject) given to patient   <PBS Script for Ferric Carboxymaltose (Ferinject) given to patient> 	
Patient’s Weight (kg): <Patient’s Weight (kg):>   (patients under 50kg can only be administered 500mg per appointment)	
Medical History attached:  <Medical History attached>	
Blood Results attached (Iron Studies and FBC):  <Blood Results attached (Iron Studies and FBC)>	
Difficult IV access:  <Difficult IV access> 	
Previous Adverse Event to Iron:  <Previous Adverse Event to Iron> 	
Further Information: <Further Information:>	
Signature:	Print name: <DrName>	
GP Practice: <Practice>	
Phone: <UsrPhone>	Date: <TodaysDate>	

ACC Use Only:	
Required within: ______ weeks	 Morning    /    Afternoon	
‹  500 mg                                       ‹  1000mg	
Referring Doctor	Signature	
Name: Helen Cooley	

Date:	
Provider No: 		
Ambulatory Care Centre
Royal Hobart Hospital
Period of Referral     3 Months		

ADMIN:	
Appointment Date:	Script Confirmed:    	
Notes:

	

Past History
<SelectedPMH>
Investigation Reports
<Ix>