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.
FatigueBrain fogShortness of breathHair thinningRestless legsPale skinCold intoleranceDizzinessHeavy menstrual cyclesNone of the above
If you checked any above symptoms, how long have you experienced them?
3. Lab Work Documents (upload required)

*** No infusion without lab confirmation.
CBC

Cancelof
Ferritin

Cancelof
Iron Panel (Serum Iron, TIBC, Transferrin Saturation)

Cancelof
CMP (recommended)

Cancelof
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
No known allergiesMedication allergies (list below)Food allergiesEnvironmental allergiesHistory of severe allergic reactions (anaphylaxis)
List your medication allergies
YesNo
Iron sucrose (Venofer)Ferric carboxymaltoseIron dextranUnknown
No reactionMild reaction (rash, nausea, flushing)Moderate reactionSevere reaction / anaphylaxis
Please describe any reactions you experienced, if any.
5. Medical History
HemochromatosisIron overloadChronic liver diseaseActive infectionAutoimmune diseaseKidney diseaseAsthmaHeart diseaseNone of the above
YesNo
6. Current Medications & Supplements
List all current medications and supplements you're taking:
YesNo
7. Contraindication Confirmation
I do not have iron overloadI have disclosed all allergiesI have disclosed prior IV iron exposureI have uploaded accurate lab resultsI understand approval is subject to medical review
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.
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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