IV Infusion Referral Form Patient Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Medicare Number, include Ref # * Email Emergency Contact (Name & Phone) * GP Name & Address If different to referring doctor Medication Allergies, including previous infusion reactions Zoledronic Acid Please ensure script provided to patient for: Zoledronic 5 mg/ 100 mL injection Indication for Infusion Date of last infusion Please attach results Blood results from within the last 2-3 months, to include renal function, calcium, vitamin D Iron Infusion Please ensure script provided to patient for: Ferinject (Ferric Carboxymaltose) 500mg Ferinject (Ferric Carboxymaltose) 1000mg Monofer (Ferric Derisomaltose) 500mg Monofer (Ferric Derisomaltose) 1000mg Indication for Infusion Patient Weight Please attach results Blood results from within the last 2-3 months, to include haemoglobin and ferritin Fluid Restriction * These infusions are typically given in 100 mL normal saline. Is this volume expected to be an issue for your patient? Yes - please attach details and contact us to discuss further No Referring Doctor * Confirmation I confirm I remain responsible for workup and all relevant follow-up/ monitoring with regard to this infusion and/ or the underlying condition being treated with this infusion Name * Provider Number * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Fax/Email/HealthLink EDI: * Referral SubmittedThank you for your referral. We will contact your patient to arrange their infusion.
