Suite 2/710 Hunter Street 
Newcastle West NSW 2302	 
p. 02 4092 7788
f. 02 4092 7789
e. hello@hunterblood.au	

Dr Karan S Makhija, Dr Wojt Janowski, Dr Ritam Prasad, Dr Sam Yuen, and colleagues

Patient Name					DOB			Mobile
Address 

Thank you for reviewing this patient for provision of an iron infusion only. 
I acknowledge that if pregnant, my patient is beyond 16 weeks gestation.
I have provided my patient with a script for Ferinject (max 1g) or Monofer (max 1.5g).

Total Intended Iron Dose 
Check one: 	☐ 500mg	 ☐ 1000mg	☐ 1500mg	☐ 2000mg
(note >1g of Ferinject or >1.5g of any iron preparation requires multiple visits)

Simplified method to calculate total body iron deficit										
	Weight <70kg	Weight >70kg	
Hb <100 g/L	1.5g	2g	
Hb >/= 100g/L	1g	1.5g	

Max single dose 20mg/kg or 1000mg for Ferinject, 1500mg for Monofer

Comments: 

Yours sincerely,

Referring Doctor

Name							Provider No. 
Address	 						Date 
Phone			          Fax			E-mail