IRON REFERRAL FORM (Only if required):
DRIP WELLNESS, PLLC www.Drip-Wellness.com info@Drip-Wellness.com
IV Therapy: Iron Infusion Referral Form
Patient Information:
Name:__________________________________________ Date of Birth: _____________________
Address: ____________________________________________________________________________
City/State/Zip: ______________________________________________________________________
Cell: __________________________________Home: _______________________________________
Email: ______________________________________________________________________________
Diagnosis(es)_______________________________________________________________________
Referring Physician:
Provider Name: _____________________________________________________________________
Clinic Name: ________________________________________________________________________
City/State/Zip: ______________________________________________________________________
Phone: ______________________________________ Fax:___________________________________
Email: ______________________________________________________________________________
IV Protocol:
Venofer (Iron sucrose) dosage: 100mg 200mg
Duration: once a week for_____________week(s). Other_________________________________
-Add mini IV drip of 0.9% Normal Saline with Vitamin C (ascorbic acid) 2000mg to follow Iron Infusion: Y/N
*Labs recommended: CBC, Iron, Ferritin, TIBC, Liver Enzymes
Physician Signature: ______________________________________ Date: _____________________
PLEASE email THIS FORM WITH LAB WORK TO : info@Drip-Wellness.com