Infusion Consent

The patient understands that the administration of FERINJECT comes with the following risks including but not limited to:

• Anaphylactic reactions, in which rare cases may be potentially fatal
• Paravenous leakage - leakage of FARINJECT at injection site, potentially leading to long lasting skin discoloration
• Skin Irritations
• Headaches, light headiness
• Tachycardia, Hyper/Hypotension
• Nausea, Stomach pain, Constipation, Diarrhoea and Vomiting
• Minor reactions from FERINJECT can occur up until 48 hours post infusion

Understanding these risks, patient gives authority for staff at the surgery to administer all necessary first aid and/or resuscitation measures, including alerting an ambulance and/or emergency contact person, in the unlikely event that an adverse or anaphylactic reaction occurs. FARENJECT is not suitable for patients in some conditions.

Patient declares that none of the below listed is applicable:

• Pregnancy in the first trimester
• Dialysis
• Allergy to Ferric Carboxymaltose
• Iron overload/haemochromotosis
• Non-iron deficiency Anaemia
• Fever/Sepsis

The Patient, has read the information provided on this document and understands the procedure is entirely at own risk and own cost and is requesting medical intervention in the form of an Iron Infusion.

The cost of the Ferinject Infusion is $170 with a $75.05 instant rebate with a valid Medicare card. Your out of pocket expense would be $94.95.

We offer Easy claim instant rebate at Asquith Doctors.

Please note that the iron needs to be purchased from the pharmacy prior to your administration appointment.

The Doctor will write a script at your first appointment.

I understand and consent to the costs incurred by this procedure: