IV IRON INFUSION REFERRAL FORM

CLINICAL INFORMATION

Please tick any that may apply

Pregnant
Fluid Restriction
Heart Failure
Renal Failure

IRON ORDER

TYPE OF IRON given in divided doses: Max 1g per infusion *

Ferinject 0.5g(x1 vial)

Ferinject 1g (X2 vials)

Ferinject 1.5g (x3 vials)

Ferinject 2g (x4 vials)

Monofer 0.5g(x1 vial)

Monofer 1g(X2 vials)

Monofer 1.5g(x3 vials)

Monofer 2g(x4 vials)

DOSE CALCULATOR

Determination of the need for Iron
HB PATIENT BODY WEIGHT
g/L 35kg - 70kg 70kg & above
<100 1,500 mg 2,000 mg
100 to <140 1,000 mg 1,500 mg
>=140 500 mg 500 mg

REFERRING DOCTOR

Draw your signature using your fingers or mouse in the box below

Please click on the Tick icon() to verify your signature. After that you can submit the form.

_

What are IV Drips?

When you consume a vitamin orally, whether it be over the counter or prescription, not everything is absorbed. What is absorbed by the stomach is taken directly to the liver where it may be metabolised. This results in only a fraction of what you consumed orally remaining into the bloodstream to be utilised as fuel and nourishes your body.

On the other hand, through IV Drips, 100% of the vitamins are delivered into your bloodstream bypassing the metabolism process. This results in the ability to get more vitamins, minerals, antioxidants, and amino acids to support your body to function at its best.