Infusion Referral - Surrey

Patient Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

Patients will be called by Mainline staff to arrange the appointment time

(###)

###

####

Is the patient pregnant? *

Yes

No

Hgb Date

MM

DD

YYYY

Ferritin Date

MM

DD

YYYY

Transferrin Saturation Date

MM

DD

YYYY

Has the patient had an ALLERGIC/ADVERSE reaction to a previous iron infusion? *

Yes

No

Does the patient have asthma/inflammatory arthritis? *

Yes

No

Orders *

Monoferric 1000mg

Monoferric 500mg

Iron Sucrose 300mg

Other

Clinic Phone Number *

(###)

###

####

Fax Number

(###)

###

####

Are you a MD? *

Yes

No (NP, ND, Midwife, etc)

Physician Name *

First Name

Last Name