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About Us
Fertility
Clinical Problems
Endosurgery
Book an Appointment
Contact
Iron Infusion
admin
2021-03-25T17:05:37+10:00
Providing professional care in fertility, gynaecology and minimally invasive surgery
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Referral For Iron Infusion
Referral For Iron Infusion
Date
*
DD slash MM slash YYYY
Referring Doctor
Name
*
Address
*
Provider Number
*
Patient Information
Name
*
First
Last
DOB
*
DD slash MM slash YYYY
Address
*
Patient Phone
*
Medicare Number
*
Referral for Ferinject
*
500mg
1000mg
Clinical indication
*
Hb
Ferritin
Other
Pregnant
*
Yes
No
Due Date
DD slash MM slash YYYY
Allergies
Has patient had ferrinject before?
*
Yes
No
Adverse reactions?
*
Yes
No
Aetiology:
*
Menorrhagia
Gastro intestinal
Other
Unknown
Gynaecology consult required?
*
Yes
No
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