Patient & Procedure Details

Patient Full Name: *

Date of Birth: *

Date of Appointment: *

Doctors Name: *

Pre-Procedure Requirements

Iron infusions cannot proceed without current pathology confirming iron deficiency. All blood results must be reviewed, and the infusion authorised by a Her Medical doctor before your appointment is confirmed.

A blood test, iron studies and full blood count (FBC), within the last 6 weeks confirming iron deficiency. Results must be available at the time of your appointment. *

Which pathology clinic did you attend for your blood test? *For example: 4Cyte Pathology, Sullivan Nicolaides Pathology, QML Pathology, etc.

GP assessment completed and infusion authorised a Healthcare Provider prior to booking. *

No known allergies or previous reactions to iron products in the past. If yes, you will need to contact the Specialty Booking team at Her Medical as a consultation with one of our GP's will be needed prior to booking this procedure. *

Not currently in the first trimester of pregnancy. Please advise the Specialty Booking team at Her Medical if you are or may be pregnant. *

Fee Schedule

Fees are listed below in full. Your out-of-pocket cost is the amount remaining after any applicable Medicare rebate.

Additional Costs

The following costs may apply separately to your consultation fees and are not included in the fees above.

Non-Medicare Cardholders

If you do not hold a valid Medicare card, the full fee applies with no rebate for any service. Please advise reception prior to your appointment.

Payment & Cancellation Policy

Your Rights & Alternatives

Financial Consent & Declaration

Please read each statement carefully and tick each box to confirm your understanding before signing.

I have been provided with a clear, itemised breakdown of all fees, including the full fee, Medicare rebate where applicable, and my estimated out-of-pocket cost. *

I understand that the iron infusion administration fee and iron medication are private charges with no Medicare rebate. *

I understand that additional costs may apply for pathology, follow-up care and further sessions if required and that I am responsible for making my own enquiries with the relevant providers about this. *

I understand that iron medication prepared for my appointment may not be reusable and agree to provide adequate notice if I need to cancel or reschedule my appointment. *

I have read and agree to the payment and cancellation policy, including that a no-show fee will incur the full consultation fee. *

I have been advised of my right to access this care through the Queensland public health system with possibly no cost and I choose to proceed with accessing this care through Her Medical. *

I understand that I may withdraw consent at any time before the infusion commences. *

If you have further questions about the financial aspects of your care, please phone the clinic and speak with our Specialty Booking team.

Patient Signature: *

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Today's Date: *