Referring Doctors

Ferinject (Ferric carboxymaltose)
mg (choose 500 mg, 1000 mg)
Higher doses can be given in divided doses 1 week apart

Monofer (Ferric derisomaltose)
mg (choose 500 mg, 1000 mg, 1500 mg)
Higher doses can be given in divided doses 1 week apart

Paediatric Ferinject (Ferric carboxymaltose)
mg
(Not to exceed 20 mg/kg and maximum 1000 mg)

Aclasta (Zoledronic Acid)
mg infusion

0.9% Sodium Chloride
mL over min

Stemetil (Prochlorperazine maleate) mg

Maxolon (Metoclopramide hydrochloride) mg

Saline Suppression Test as per Clinic Procedures. Give 2 Litres 0.9% Sodium Chloride over 4 hours (rate: 500 mL/hour). If potassium level within normal limits within 7 days prior to test proceed with infusion. If potassium levels abnormal consult referring physician prior to proceeding. (Referring Physician: Please give script for Prazosin hydrochloride 0.5 mg orally to be given as needed for BP greater than 180/100 and 2 lab referral forms)

Other (Please include dose and rate of infusion)

Comments and Any Administration Notes