Iron Infusion Form

Iron infusions are used to treat iron deficiency when oral supplements are ineffective or not tolerated. The procedure involves delivering iron directly into your bloodstream via an intravenous drip in our clinic. Our team will assess your iron levels and determine if this treatment is suitable for you.

Please book an appointment to discuss iron infusion treatment.

Download Consent Form

Patient Information

Contraception | Andrew Place Clinic | Mill Park and Bundoora

Iron Infusion (Ferinject®) Patient Consent Form

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This field is for validation purposes and should be left unchanged.

Patient Name(Required)

First Last

DOB

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Part 1

Does the patient have capacity?

Yes

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

Category of MTDM

Name of substitute MTDM

Part 2

Is an interpreter required?

Yes

Interpreter required

In-person

Telephone

Language

Name of interpreter

Signature (if in-person)

Part 3

Patient OR MTDM requests the Iron infusion (Ferinject®).

Specific issues in setting of:

Liver disease

Reduced kidney function

Prolia therapy

Other

Not included in the patient information booklet the following patient-specific issues have been discussed:

Risks in having iron infusion:

Risks in NOT having iron infusion:

Alternative treatment options:

Part 4

g/L

Ferritin

micrograms/L

Test Date

Today’s Weight

Ferinject dose

Simple method

Ganzoni Method

Follow-up

Blood test

approx. date)

Pathology request given to patient

Calcium/Phosphate check ordered for

Restart oral iron

No or N/A

Yes

Yes from

Not within 5 days)

Part 5

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.

Part 6

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.

Patient Name

First Last

DOB

Date of Birth

Patient Signature

MTDM Name

First Last

MTDM Signature

Doctor Name

First Last

Doctor Signature

Date

Your health starts here

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Iron Infusion (Ferinject®) Patient Consent Form

Part 1

Part 2

Part 3

Part 4

Part 5

Part 6

Your health starts here

Bundoora

Mill Park