REFERRAL FORM
Email all Referrals to:    info@sainfusion.com.au
OR Fax to:  (08) 7081 7038

PATIENT DETAILS
	REFERRER DETAILS
	
Full Name: <PtFullName>
	Full Name: <DrName>
	
Address: <PtAddress>
	Provider No.: <DrProviderNo>
	
Date of Birth: <PtDoB>
	Practice: <Practice>
	
Contact Phone: <PtPhoneMob>
	Phone: <UsrPhone>
	
Medicare No: <PtMCNo> - <PtMCLine>
Expiry: <PtMCExpiry>
	Fax: <UsrFax>

DETAILS OF REFERRAL
[<Have you attached ALL of the required Pathology Results? - CBE, LFTs & Iron Studies (PREFERABLY PERFORMED WITHIN THE LAST 6 WEEKS)>]  I have attached the required pathology results — CBE, LFTs & Iron Studies (performed within the last 6 weeks)
Criteria for Iron Infusion met by Referred Patient (select ALL that apply):
[<Tick ALL the criteria for Iron Infusion which the patient meets (select ALL that apply):>] 
Is the patient pregnant? [<Is the patient pregnant?>]
Age: <PtAge>

[<Is the patient aged 14 years or older?>] Patient aged ≥ 14 years old 

(SA Infusion Services is only able to accept referrals for non-pregnant patients, aged 14 or older)

Weight (kg): <What is the patient's weight? (in kilograms)>
Allergies: <Reactions>	
Has the patient had any previous reactions to intravenous iron? <Has the patient had any previous reactions to intravenous iron? (if YES, please provide further details)>

REFERRER ACKNOWLEDGEMENT

By signing this referral form, the referrer fully accepts & acknowledges that investigation of the underlying cause(s) of the patient's iron deficiency, and treatment of these causes, are NOT the responsibility of SA Infusion Services and solely remain the referrer’s responsibility. Referrer also accepts it is their responsibility to follow-up the results of the iron studies blood test to be performed typically 6 to 8 weeks after the iron infusion.

Referrer MUST also provide the patient with instructions for oral iron supplementation if currently being taken. Patients under the age of 18 must present to their appointment with a parent or guardian.
  
For patient convenience, we ask that the referrer kindly provides the patient with a script for their IV iron medication at the time of their referral, if able. If not able, we will endeavour to organise a script for the patient. 

Dosing Guideline Table for IV iron medication is provided below:

GP / Referrer Signature: ____________________________

Date:  <TodaysDate>

<Ix>