Follow the Advance Care Directive (ACD), or if there is no ACD, obtain consent from the legal substitute medical treatment decision maker (MTDM).

Fee payable for all patients is $302 per infusion including a $100 deposit required at the time of booking. Prescription cost for Ferinject is not included. Where total dose exceeds 1gram this requires 2 infusions at least a week apart. The same total fee applies for second infusion.

I acknowledge that the doctor has explained the “Iron infusion” information brochure including:

• Iron deficiency anaemia, benefits of iron replacement treatment, and the options available including Ferinject®. More than 1 infusion and/or additional treatment may be required.
• Possible risks in not having Ferinject® Inlcuding ongoing tiredness, worsening anaemia.
• General/specific risks of Ferinject® including possible side effects: - Feeling sick or vomiting, - Temporary metallic taste changes , headache, muscle or joint pain, low blood phosphate. - Blood pressure changes, shortness of breath, itchy skin or rash - Uncommon, but possible risk of long lasting or permanent brown skin discolouration called iron staining and the possible severity (Refer colour images p3). - Rare risk of serious allergic reaction called anaphylaxis, which can be life threatening. - Risks with any current/possible infection, or if pregnant (tell doctor if pregnant / trying) - Complication risk if given within 3 months of a Denosumab (Prolia) injection
• If a life-threatening event occurs during the procedure, treatment will be based on any documented discussions such as an advance care directive (ACD)
• I understand and agree to immediately notify the nurse or doctor present during the procedure if I have any reactions, concerns or discomfort / swelling or pain at the needle (drip) site.
• I understand the out-of-pocket costs and know that a doctor/nurse other than the consenting doctor is likely to administer therapy and provide appropriate treatment on the day of infusion.
• I was able to ask questions and raise concerns with the doctor.

If I choose not to consent, it will not negatively affect my access, outcome or rights to medical treatment in any way. I understand I have the right to change my mind (withdraw consent) at any time, including after signing this form (this should be in consultation with the doctor/clinician).

I / MTDM have received the consumer information booklet titled “Iron infusion”. Informed (as above), I consent to having the Ferinject® iron infusion therapy.