Iron Infusion GP Referral Form

Patient
Date of Referral  	<<Miscellaneous:Date>>	DOB 	<<Patient Demographics:DOB>>	Age		
Name	<<Patient Demographics:First Name>>	Gender	<<Patient Demographics:Gender>>	
Address 	<<Patient Demographics:Full Address>>	
Home Number	<<Patient Demographics:Phone (Home)>> 	Mobile   	<<Patient Demographics:Phone (Mobile)>>	

Carer/Emergency Contact Information
Name		Relationship to patient		
Home Number		Mobile Number		

Allergies		
Weight			Pregnant?
	YES / NO	

Indication for Iron Infusion

Significant Past history

List or attach Current Pathology Report for HB and Ferritin

HB:                           Date: 

Ferritin:                       Date:	

Iron Order (please attach script):

q Ferinject 500mg	q Ferinject 1000mg	q Ferinject ____________

(Information on page 2 for dosage)

Contraindications
 Known hypersensitivity to Ferinject® or to any of its excipients;
 Use with caution in pts. with elevated liver enzymes or active substance abuse. 
 Confirmed previous reaction to intravenous iron to be assessed by Medical Practitioner Anaemia not attributed to iron deficiency, e.g. other causes of microcytic anaemia; 
 Evidence of iron overload or disturbances in utilisation of iron;
 Pregnancy in the first trimester.

Dosage per Infusion:

•	Maximum dose of Ferric Carboxymaltose (Ferinject®) per infusion is 20mg/kg to maximum of 1000mg. Use ideal body weight in overweight patients. 
•	The first dose of Ferric Carboxymaltose (Ferinject®) is given at 20mg/kg to a maximum of 1000mg. 
•	A second dose may be given ≥1 week later to replace the remainder of the calculated total body iron deficit (see table below) but not exceeding maximum dose per infusion of 20mg/kg to a maximum of 1000mg. 
•	In patients with ongoing blood loss or requiring surgery associated with substantial blood loss, 20mg/kg to a maximum of 1000mg can be given for both doses.

ADULT: Approximate total body iron deficit & dosage per infusion of Ferric Carboxymaltose (Ferinject®) – circle appropriate box. 

Hb (g/L)	*Body weight 35 to <50 kg	*Body weight 50 to <70 kg	*Body weight ≥70 kg	

#Hb ≥100 g/L	Total deficit: 1000 mg
       1st dose:   500 mg
       2nd dose:   500 mg	  Total deficit: 1000 mg
   1st dose:   1000 mg
  2nd dose:   not required	Total deficit: 1500 mg
  1st dose: 1000 mg
  2nd dose:   500 mg	

#Hb <100 g/L	Total deficit: 1400 mg
        1st dose:   700 mg
       2nd dose:   700 mg	  Total deficit: 1500 mg
   1st dose:   1000 mg
   2nd dose:     500 mg	Total deficit: 2000 mg
  1st dose: 1000 mg
  2nd dose: 1000 mg	
*Use ideal body weight in overweight/obese patients (If underweight, use actual body weight).

This treatment has been explained to the patient including the treatment proposed, the reason for the treatment and the risks and complications that could arise as a result of this treatment. I advise that there are no medical contraindications for this patient to receive this treatment.	

Referring GP  
Name	<<Doctor:Name>>	Provider Number	<<Doctor:Provider Number>>	
Practice Name		
Address	<<Doctor:Full Address>>	
 Phone	<<Doctor:Phone>>	Fax	<<Doctor:Fax>>	
 Mobile		Email	<<Doctor:E-mail>>	

Signature 		Date	<<Miscellaneous:Date>>