Iron IV Infusion Medical History and Consent

Iron IV Infusion Medical History & Consent
1. Personal Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Height
Weight (in pounds)
2. Symptom Assessment

Please answer the following questions honestly. Your safety depends on accurate information.
Are you currently experiencing:
If you checked any above symptoms, how long have you experienced them?
3. Lab Work Documents (upload required)

*** No infusion without lab confirmation.
CBC

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Ferritin

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Iron Panel (Serum Iron, TIBC, Transferrin Saturation)

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CMP (recommended)

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Minimum lab criteria for consideration typically includes:

Ferritin < 50 ng/mL (symptomatic); Transferrin Saturation < 20%
Other antidepressant or serotonergic drugs:
4. Allergy & Prior Iron Exposure Screening
Do you have any known allergies?
List your medication allergies
Have you EVER received IV iron before?
If you have had an iron infusion before, which product was it?
Did you experience any reaction?
Please describe any reactions you experienced, if any.
5. Medical History
Have you ever been diagnosed with:
Are you pregnant or breastfeeding?
6. Current Medications & Supplements
List all current medications and supplements you're taking:
Are you currently taking oral iron?
7. Contraindication Confirmation
Please confirm all
8. IV Iron Sucrose Consent Acknowledgment
Iron sucrose is administered intravenously to treat iron deficiency.

Potential risks include:
- Nausea
- Headache
- Low blood pressure
- Injection site irritation
- Allergic reaction
- Rare anaphylaxis
I understand emergency medications are available during infusion.
Signature
Date

MonthDayYear
Date
Should be Empty:

Iron IV Infusion Medical History & Consent

1. Personal Information

2. Symptom Assessment

3. Lab Work Documents (upload required)

Minimum lab criteria for consideration typically includes:

4. Allergy & Prior Iron Exposure Screening

5. Medical History

6. Current Medications & Supplements

7. Contraindication Confirmation

8. IV Iron Sucrose Consent Acknowledgment