NEW Infusion Request CAREPACT

IV Infusion Booking Form

For Iron and other infusions overseen by CAREPACT, delivered via Modia Health
Patient details
Patient Name:

First NameLast Name
Patient DOB:

DayMonthYear
Date
Medicare card and reference number:
E.g., 4019 56315 1 1
Aged Care Facility:
Facility Name:
Facility Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Order details
Eligibility for Iron Infusion *
Please elaborate if Other selected:
Does this Resident have diagnosis of Heart Failure? *
Request Date:

DayMonthYear
Date
Medication Type:
Infusion Order:
Dose:
If you need assistance on dosing, please contact the CAREPACT specialist consultant hotline for GPs and NPs (0437 252 746)
Dose 2:
Patient weight:
Weight must be recent (within last month).
Date weighed:

DayMonthYear
Date
Consent obtained:
Was consent verbal or documented?:
If verbal, please provide the contact name and number with whom consent was discussed:
Consent contact name:

First NameLast Name
Consent contact number:
If verbal, please provide the contact name and number with whom consent was discussed:
Consent documentation:

Cancelof
Documentation
Blood results:

Cancelof
IV Iron Infusions
For IV Iron, blood tests must be within the last month and include:
- FBC
- Chem20
- CRP
- Iron studies
Please refer to the Queensland Health work instruction:
Administration of Intravenous Iron Infusions (Adult)

Aclasta (Zoledronic Acid) Infusions
For Aclasta, blood tests must be within the last 4 weeks and include:
- FBC
- Renal function (e.g., creatinine / eGFR)
Please refer to the Queensland Health work instruction:
Administration of intravenous zoledronic acid infusion
Medication Chart:

Medication chart must include the medication to be administered.
Cancelof
Medication has been charted:
Family member / NOK / EPOA details
Name:
Phone number:
Email address:
Your details
Who is completing this form?
Name and position
Send a copy of booking request to email address:
Should be Empty:

IV Infusion Booking Form

Patient details

Order details

Documentation

Family member / NOK / EPOA details

Your details