Medical Infusion

Intralipid Treatment Schedule
Number of sessions required? (option 1 - 5). *
NB: For Pre- Pregnancy Treatment Schedule. A referral covers 4 pre-pregnancy intralipid infusion sessions only.
1st Treatment

MonthDayYear
Date
2nd Treatment

MonthDayYear
Date
3rd Treatment

MonthDayYear
Date
4th Treatment

MonthDayYear
Date
5th Treatment

MonthDayYear
Date
Pregnant Patients

Disclaimer:Pregnancy Intralipid Infusions are scheduled once every two weeks, up to a maximum of 14 weeks gestation. We will make every effort to accommodate patients within 1-2 days of their requested date. Please note that pregnancy hCG levels must be above 100 to qualify for Intralipid Infusions
Date of Pregnancy Blood Test

MonthDayYear
Date
hCG Level

Referring Doctor Details
Name*

First NameLast Name
Speciality*
Provider Number*
Phone Number*
Please enter a valid phone number.
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specialist Signature

By signing below, I confirm that I have gained the patient's informed consent for procedure/treatment outlined in this form, after discussing the risks, complications and alternatives with the patient. The patient understands they may withdraw consent at any time.
Signature*

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Date*

MonthDayYear
Date
The Infusion Centre

306 Olsen Avenue

Parkwood, QLD 4214

+61 449 916 829

info@theinfusioncentre.com.au
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Clinical Information