Plan request

Iron Infusion

Please ensure the following labs have been done within 30 days of the Therapy Plan Request:
CBC / Iron / Ferritin

Complete this form as comprehensively as possible, then select Save as PDF and send it to us. If you'd rather fill it out by hand, instead.

Unfortunately, we cannot enter therapy plans for those under the age of 18.

Requesting Prescriber Details

Full Name Required

PracID Required

Clinic Name Required

Fax Number Required

Patient Demographics

(You may attach a patient label if completing the form manually)

Last Name

First Name

Healthcare Number Required

Date of Birth

Telephone Number Required

Preferred Day Medicine site Required

Foothills Medical Centre Peter Lougheed Centre Rockyview General Hospital South Health Campus UrgentAll urgent requests are usually booked at South Health Campus. Your patient must be willing to travel there on short notice.

Pertinent Medical History

(You may enter information here, OR attach details to this form when submitting)

Medical and Surgical History Required

Current Medications Required

Allergies Required

No known allergies Other

Indications for Iron

We follow Calgary Day Medicine Guidelines for iron infusion: women with hemoglobin less than 120 g/dL, or men with hemoglobin less than 135 g/dL.

Specialist Link Iron Pathway

Specific guidance for pregnancy

Please ensure the following labs have been done within 30 days of the Therapy Plan Request: CBC / Iron / Ferritin.

Reason for IV Iron Required

Celiac Disease GI Bleed Malabsorption (Bypass Surgery) Menorrhagia Malignancy Nutritional deficiency Unknown / Under Investigation Other

Type of Iron Requested and Special Authorization

If these fields are not completed, we may not be able to enter your Therapy Plan Request in a timely manner.

Please review with the patient whether they have private drug coverage to pay for Monoferric, or, if they are over the age of 65, complete an Alberta Blue Cross Special Authorization form.

If they do qualify for Monoferric (Ferric derisomaltose), please provide them with a prescription to collect at their pharmacy and bring to the infusion appointment at Day Medicine.

There is no charge for adult Day Medicine Infusion appointments, nor for Iron Sucrose, if patients meet the criteria set by Alberta Health Care and Day Medicine-specific policies. Failure to show for appointments may result in cancellation of the plan and any remaining infusions of iron.

Infusion Product Required

Iron Sucrose (Venofer). Dosage is decided by the practitioner entering the Therapy Plan. Typically 3 doses. Ferric derisomaltose (Monoferric). Typically a single dose.

If Monoferric was chosen

If these fields are not completed, we may not be able to enter your Therapy Plan Request in a timely manner.

Confirmations

Requesting Practitioner has confirmed private coverage and provided prescription Requesting Practitioner has confirmed Alberta Blue Cross coverage and provided a prescription The patient has been informed that they must collect the medication at a community pharmacy and bring the product with them to the infusion appointment

Iron Therapy

Select all that apply.

Iron therapy Required

The following labs have been done within 30 days of the Therapy Plan Request: CBC / Iron and Ferritin Has received previous IV iron infusion without side-effect or reaction Has previously had IV iron infusion AND had a reaction (please specify the reaction in the Other box below) Other

Save this form as a PDF, so you can print it and fax it to us at (403) 879-5049.