IRON INFUSION REFERRAL FORM
AMBULATORY CARE CENTRE (ACC)
ROYAL HOBART HOSPITAL
PHONE: 6166 8065
FAX: 6173 0270	Patient Details      	

SURNAME: <<Patient Demographics:Surname>>	
D.O.B: <<Patient Demographics:DOB>>	

OTHER NAMES: <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>	
SEX: <PtSex>	

ADDRESS: <<Patient Demographics:Address>>	

PHONE: (h) <<Patient Demographics:Phone (Home)>> (m) <<Patient Demographics:Phone (Mobile)>>	

	

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) giv>> 	
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: <<Doctor:Name>>	
GP Practice: <<Practice/Location:Name>>	
Phone: <<Practice/Location:Phone>>	Date: <<Miscellaneous:Date>>	

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

Provider No: 	

Ambulatory Care Centre
Royal Hobart Hospital
Period of Referral     3 Months	

Date:	

ADMIN:	
Appointment Date:	Script Confirmed:    	
Notes:

	

Past History
<<Clinical Details:History List>>
Investigation Reports
<<Summary:Investigation Results (Selected)>>