Iron Infusion with FERINJECT - Consent Form

This consent form is to help you decide and confirm your consent to proceed with an iron infusion. All treatment have benefits and risks.

Benefits

An iron infusion is an effective way to supplment your iron levels. It is often used when you cannot tolerate oral treatments or oral treatments have failed. Improving your iron levels helps to treat anaemia and can help with energy and builds your iron levels.

Risks

The following are risks and potential side-effects of an iron infusion:

Anaphylactic reactions, which in rare cases may be potentially fatal

Paravenous leakage - the iron infusion may leak at the at injection site and if this occurs it may lead to long lasting skin discolouration

Skin Irritations

Headaches and lightheadedness

High heart rate (tachcardia)
High or low blood pressure (Hyper/Hypotension)
Gastric side effects such as nausea, stomach pain, constipation, diarrhoea and vomiting

Minor reactions to FERINJECT may last up to 48 hours post injection.

Click here to see a more detailed list of side effects. By clicking here you confirm that you have reviewed the list of side effects. *

Common Side Effects	Uncommon and rare side effects
These are side effects that occur between 1-10% of the time.	These are side effects that occur less than 1% of the time.
Headache Flushing Nausea Low blood phosphate levels Injection/Infusion site reactions including superficial thrombophleblitis	Hypersensitivity Numbness Increased heart rate Hypotension Difficulty breathing Taste disturbance Vomiting Dyspepsia Flatulence Abdominal pain Constipation Diarrhoea	Hives (urticaria) Redness (erythema) Rash Muscle pain or spasm Back, joint or chest pain Fever Fatigue Accumulation of fluid in periphery Pain and chills Anaphylaxis Rigors Malaise Itchiness

FERINJECT is not suitable for patients with some conditions. By ensuring each of the boxes below is ticked you declare that those situations do NOT apply to you.

I confirm I am not pregnant in the first trimester *

I confirm that I am not on a dialysis program *

I confirm that I am not allergic to Ferric Carboxymaltose (Ferriinject) *

I confirm that I do not suffer with an iron overload condition such as haemochromatosis *

I confirm that I am older than 14 years of age *

I confirm that I am NOT suffering with a fever *

I understand and accept that this procedure involves insertion of an IV cannula and will require me to remain for 15 minutes after the procedure has been completed in the clinic. *

I have had the opportunity to ask questions about the above procedure and I am satisfied I understand the information I have received and hereby consent to the procedure of an iron infusion. *

First Name *

Last Name *

Please enter your date of birth *

Date

Signature

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