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

Preferred Location for Infusion: <What is the patient's preferred location for the Iron Infusion? (select ALL locations they can attend)>

PATIENT DETAILS
	REFERRER DETAILS
	
Name: <PtFullName>
	Doctor Name: <DrName>
	
Address: <PtAddress>
	Provider No.: <DrProviderNo>
	
Date of Birth: <PtDoB>
	Practice: <Practice>
	
Contact Phone: <PtPhoneMob>
	Phone: <UsrPhone>
	
Date: <TodaysDate>
	Fax: <UsrFax>

TO BE COMPLETED BY GP / REFERRER
[<Have you attached ALL of the required Pathology Results? - FBC, Iron Studies, LFTs (PREFERABLY WITHIN LAST 4 WEEKS)>]  Pathology results attached: FBC, iron studies, LFTs — PREFERABLY WITHIN LAST 4 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 only provides infusions to patients aged 14 or above.)

Note: If patient is less than the age of 18, they must present with a parent or guardian.
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)>

PLEASE NOTE:

Investigation of the underlying condition(s) and treatment are NOT the responsibility of SA Infusion Services and remains the referrer’s responsibility. Referrer to consider a separate referral to appropriate specialty if required. It is the referrer’s responsibility to follow up results of the iron studies which will be performed 6 weeks after the iron infusion.

Referrer MUST also advise patient on plan with oral iron supplementation if currently being taken (general advice would be to stop oral iron 7 days prior to the iron infusion and for 5 days after the infusion). 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>