IV IRON INFUSION REFERRAL FORM

CLINICAL INFORMATION

Please tick any that may apply

Pregnant
Fluid Restriction
Heart Failure
Renal Failure

IRON ORDER

TYPE OF IRON given in divided doses: Max 1g per infusion *

Ferinject 0.5g(x1 vial)

Ferinject 1g (X2 vials)

Ferinject 1.5g (x3 vials)

Ferinject 2g (x4 vials)

Monofer 0.5g(x1 vial)

Monofer 1g(X2 vials)

Monofer 1.5g(x3 vials)

Monofer 2g(x4 vials)

DOSE CALCULATOR

Determination of the need for Iron
HB PATIENT BODY WEIGHT
g/L 35kg - 70kg 70kg & above
<100 1,500 mg 2,000 mg
100 to <140 1,000 mg 1,500 mg
>=140 500 mg 500 mg

REFERRING DOCTOR

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