Iron Infusion (Ferinject) Consent Form

IV Iron Infusion (Ferinject) Consent Form
Patient Name*

First NameLast Name
Has this patient received an iron infusion previously?*

YesNoUnsure
Diagnosis of Iron deficiency: The patient named above has low levels of iron in their body (iron deficiency and/or anaemia).

Recommendation: The doctor has recommended treatment with a Ferinject intravenous iron infusion. The aim of the iron infusion is to boost you body's iron stores. Initially, we usually treat this condition with oral iron replacement in the form of a tablet or liquid, however this is often not effective, or causes side effects such as stomach pain and constipation. In this case, your GP has recommended an IV Iron Infusion. Dr Molloy will perform the procedure at the nursing home.

Ferinject Iron Infusion Patient Information

Please ensure you read the Ferinject Patient Information sheet via the link below.
CLICK HERE for the Ferinject Patient Information sheet.
How long?

The procedure takes about 1 hour in total.

What are the risks?
- Severe allergic reaction such as anaphylaxis
- Long-lasting brown discolouration and irritation of the skin around the IV site
- Headaches and dizziness
- Rapid heart rate or change in blood pressure
- Nausea, abdominal pain, constipation, diarrhoea, vomiting
- Low phosphate levels, high ferritin (iron) levels
- Minor reactions can occur upto 48 hours after the infusion
What is the cost?

$149.00 per procedure performed by our doctor, payable to Elder Medical.

Declaration of Consent

Ferinject IV Iron Infusion Procedure
I consent for Ferinject IV Iron Infusion to be performed for the patient named above as deemed necessary by the treating doctor.*

YesNo
Your Full Name*

First NameLast Name
Email*
example@example.com
Signature*

Clear

Payment Information
Have you already provided a payment method to Elder Medical for GP Services?*

YesNo
Do you give permission for the procedure fee of $149.00 AUD to be charged to the payment method that we already have on file?*

YesNo (please provide a payment method below)

IV Iron Infusion (Ferinject) Consent Form