Iron infusion informed financial Consent

First Name *

Last Name *

Date of birth *

Date of Procedure *

Doctor *

Please note;

This is a 45 minute procedure with our nurses. We are unable to accomodate children within this procedure. We ask that you please make altertivate arragnements for your children during this time.

In order to proceed with your planned infusion we require patholgy from within the last 6 weeks. If you have not done them we will not be able to proceed. *

I understand that my infusion will not proceed without recent pathologyI confirm that i can provide investigations from the last 6 weeks

Do you have a copy of your results ?

Browse

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

4CyteQMLSullivan Nicolaides Pathology Other

Is there a chance you are in the first trimester of pregnancy? *

YesNoUnsure

Financial Consent

Type of Appointment	Fee	Medicare Rebate
1. Iron Infusion	$295.00	$43.90
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:

Patients name *

Date: *

Signature *

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