For Healthcare Providers

Online Referral Form

Complete the form below to refer a patient for IV iron infusion. You may also download the PDF referral form and fax it to (604) 398-6450.

Patient Information

Patient Name *

PHN *

Date of Birth *

Phone Number

Patient Email

Pregnant?

Yes No

Serious infusion reaction to IV iron in past?

Yes No

Indication

Iron deficiency (ID) or Iron deficiency anemia (IDA) — oral iron ineffective or not tolerated Iron deficiency in heart failure (HFrEF) Other

If other, please specify

Drug Coverage

Extended health plan None

Recent Lab Values

Labs must be within 2 months.

Date of Labs *

Hgb (g/L)

Ferritin (ug/L)

TSAT (%)

Prescription

Ferinject (ferric carboxymaltose) or Monoferric (ferric derisomaltose) — dose calculated by clinic based on weight and Hgb.

*Final iron formulation and dose to be determined by Hematology.

Referring Physician

Physician Name *

MSP #

Clinic Name / Phone *

Fax / Email *

Additional Notes

Patients can expect a call from the clinic within 1-3 business days of the referral being received.

Please also fax relevant patient medical history, allergies, and current medication list to (604) 398-6450.

This form transmits referral information via email. By submitting, you confirm that you are an authorized healthcare provider and that the patient information provided is accurate. Please also fax supporting lab work to (604) 398-6450.

Referral submitted

Thank you. Your referral has been received. We will contact the patient to schedule their appointment. Please fax supporting lab work to (604) 398-6450 if not already sent.