iron infusion consent form

HFGP Consent Form to Receive Intravenous Iron Replacement Therapy

You have been recommended to receive an iron infusion in order to correct your iron deficiency and/or anaemia

Patient Details

First name *

Surname *

Date of Birth *

All medications have risks and side effects. It is important that you understand the specific side effects with iron infusions.

Please read and cross the below statements to indicate that you have been told of these side effects and understand their implications.

My treating Doctor has discussed with me the risks and the possibility of complications, including :

Leakage from the vein at the injection site which may lead to long lasting or permanent brown discoloration and staining in the skin *

Severe allergic reactions (anaphylaxis) which may be fatal *

Skin irritations *

Palpitations, headache, dizziness *

Nausea, abdominal pain, constipation and or vomiting *

By signing this form, you confirm that:

I have been informed that iron infusions should be used only after adequate trials of oral iron tablets or under specific circumstances as advised by my doctor or specialist *

I have had the opportunity to discuss and clarify any concerns with my doctor *

I understand that in the event of an emergency during the procedure, I will be treated, and if needed an ambulance called, and sent to hospital. I understand that this may incur extra cost. *

I have been informed about the out of pocket charges for the infusion is $170 (plus any associated consultation) and that $170 is not refundable from Medicare.I understand that I may need more than one infusion. *

Signature *

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Date *