Iron infusion informed financial Consent

First Name *

Last Name *

Date of birth *

Date of Procedure

Doctor

Have you had a blood test in the last 6 week ? *

Yes No

Do you have a copy of your results ?

Browse

If you don't, where did you have your blood test ?

4CyteQMLSullivan Nicolaides Pathology Other

"The clinical information included in this financial consent form is intended solely to aid you in making an informed decision regarding the procedure for which you are granting financial consent. Meaningful clinical discussions with your physician are vital and will take place on the day of the procedure. We strongly encourage you to ask any questions you may have and to confirm your confidence in the consent you provide."

Why are people referred for iron infusion?

Intravenous iron infusion might be indicated if you suffer from iron deficiency anaemia where you have been unable to tolerate oral supplementation, or where oral supplementation has failed to improve your iron store.

Iron is needed for the production of oxygen carrying red blood cells. The cause of your individual iron deficiency needs to be investigated.

How is an iron infusion delivered?

Iron infusion is a procedure in which iron is delivered to your body intravenously, meaning into a vein through a needle. this method of delivering medication is known as IV infusion. Iron infusions are usually prescribed by your doctor to treat iron deficiency and anemia.

How many iron infusions are required?

Usually 1 to 3 iron infusions are given 1 week apart. The severity of your anemia is among the deciding factors in ascertaining iron dosage.

How long will the infusion take?

Ferinject is given by infusion into a vein in your arm through a drip. The infusion runs over 15 minutes. It is critical at this stage that you keep your arm still to prevent the cannula coming out. It is very important that you inform your care provider immediately if you think that the cannula has come out, or you are feeling pain/stinging/burning in your arm. You will be booked so that there will be 10-20 minutes prior to the infusion to take observations and insert an IV cannula. You will also be required to stay on the premises for 30 minutes after the infusion. The whole process will take approximately one hour.

Side effects

Iron infusions are generally well tolerated.

Common side effects (5:100) include:

• Headache, dizziness, high blood pressure, flushing nausea, and skin reactions at the IV/drip site

• The skin reaction is generally pain, redness or bruising at the drip site

• Uncommonly this can include permanent brown discolouration at the IV site

Uncommon side effects (<1:100) include

Mild allergic reaction
Numbness in the arm
Low blood pressure
Shortness of breath
Vomiting
Heartburn
Stomach pain
Constipation
Diarrhoea
Itchiness
Back pain
Chest pain
High temperature
Rash
Hypersensitivity
Numbness
Increased heart rate
Hypotension
Difficulty breathing
Taste disturbance
Dyspepsia
Flatulence
Abdominal pain
Itchiness
Hives (urticaria)
Redness (erythema)
Muscle pain or spasm
Back, joint or chest pain
Fever
Fatigue
Accumulation of fluid in periphery
Pain and chills
Anaphylaxis
Rigors
Malaise

Sometimes side effects may start 1-2 days after the infusion and generally settle within 7-10 days

Unless you have an unexpected reaction you will be able to drive home and resume normal activities

Financial Consent

Type of Appointment	Fee	Medicare Rebate
1. Iron Infusion	$285.00	$41.40
2. Iron vial	$ 45.00	$0.00

Do you understand that the fees quoted are for Iron related consultations only? If you are consulted for unrelated conditions, in addition to this procedure, you will be charged an additional fee. *

I have read and understood the information and fee structure associated to the Iron Infusion. *

I have further questions regarding the financial section. I would like a specialist admin team member to discuss this with me further prior to my procedure date:

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Date: *