NEW REFERRAL FOR POAC FUNDED FERRIC CARBOXYMALTOSE INFUSION (FERINJECT)

IV IRON INFUSION REFERRAL

Referral for a POAC funded community based IV iron infusion (for patients aged 14 years and over only)
The patient is 14 years or over, has been informed, and consents to this referral*

Yes
Patient is eligible for NZ public health funding*

Yes - NZ resident or citizen (including those from the Cook Islands, Niue or Tokelau)Yes - Two years continuous working visaYes - Reciprocal agreement with UK, AustraliaNo
The patient must be eligible for publicly funded primary health care. This is not included as part of maternity funding. Please check this prior to referring.

See Te Whatu Ora guide to eligibility HERE
Haemoglobin and, where required, Ferritin have been completed within the four weeks prior to referral OR within three months for renal patients. (Ferritin is required for all patients except those referred under Specialist recommendation). Results used must be the most recent recorded.*

YesNo
Phosphate testing required?*

Patient has had two or more iron infusions in preceding 6 monthsRisk of hypophosphataemia e.g. BMI < 18, poor nutrition, chronic diarrhoeaNone of the above applies
Phosphate
Phosphate MUST be tested prior to referring for this patient
Blood results must be completed within the four weeks prior to referral date. For renal patients, this is extended to three months.

Please arrange repeat blood test for Ferritin and/or Haemoglobin
Referral type*

Antenatal patientPostnatal patientOther patientsSpecialist recommendation
Specialist recommendation

The patient must be diagnosed with iron deficiency anaemia (HB less than 115 female, less than 130 male). Name of specialist to be documented.
IV iron infusion is recommended by:*

internal medicine physicianobstetriciangynaecologistanaesthetist
Name of specialist*
The specialist's name is required for POAC funding.
The recommendation is on the grounds that:*

Patient has been compliant with oral iron treatment and treatment has proven ineffectiveTreatment with oral iron has resulted in dose-limiting intolerancePatient has symptomatic heart failure, chronic kidney disease stage 3 or more or active inflammatory bowel disease and a trial of oral iron is unlikely to be effectiveRapid correction of anaemia is requiredNone of the above
Ferritin
If tested
Gender*

MaleFemale
Haemoglobin*
Must be less than 115 female or 130 male (blood results within 2 weeks)
Antenatal
Warning: this referral is only for pregnant women for treatment of anaemia with NO OTHER OBSTETRIC RISKS

Seek obstetric advice if:

- anaemia AND >37 weeks gestation

- Hb 34 weeks gestation

- first trimester pregnancy

- concern about symptoms
Is the woman over 37 weeks gestation OR is there intrauterine growth restriction (IUGR) OR is there reason for an obstetric consult?*

None of these applyYes - please seek obstetric advice before referringYes - proceed with infusion, as endorsed by SMO
Name of obstetric SMO endorsing*
PLEASE SEEK OBSTETRIC ADVICE. DO NOT PROCEED WITH THIS REFERRAL
Antenatal ferritin level*
Must be less than/equal to 20 mcg/L (blood results within four weeks)
Antenatal Hb level*
Must be greater than 70g/L and less than 110 g/L (blood results within four weeks)
Antenatal Criteria*

Failure of a trial of oral iron therapy due to significant side effectsPersistent anaemia after 4 weeks despite compliance with oral therapyRapid correction of anaemia is requiredNone of the above
This referral is for pregnant women for treatment of anaemia, less than 37 weeks gestation, with NO OTHER OBSTETRIC RISKS.

Where this applies, do not proceed refer for obstetric secondary consult
Postnatal
Postnatal ferritin level*
Must be less than/equal to 20 mcg/L (blood results within four weeks)
Postnatal criteria*

Rapid correction is required due to Hb less than 90g/LRapid correction is required due to Hb less than 100g/L WITH symptoms of anaemiaNone of the above
Other patient criteria
Patient ferritin level*
Must be less than/equal to 20 mcg/L (blood results within four weeks)
Gender

MaleFemale
Patient haemoglobin level*
For Male the Hb must be less than 115g/L and for Female must be less than 100 g/L (blood results within four weeks)
Other patient criteria*

Failure of a trial of oral iron therapy due to significant side effectsPersistent anaemia after 4 weeks despite compliance with oral therapyRapid correction of anaemia is requiredNone of the above
Special Authority Number*
Pharmac Special Authority MUST be completed by the endorsing specialist where more than 115 female or 130 male
Unfortunately based on the information provided, this patient is not eligible to receive POAC funded IV iron infusion.

Please review the funding criteria HERE or contact POAC

Phone 09 535 7218

Email referral@poac.co.nz
REFERRAL DETAILS
Date *

DayMonthYear
Date
Referred from*

General Practice/Urgent CareSecondary renal serviceSecondary pre-operative serviceSecondary obstetrics teamMidwifePatient blood managementOther
Name of referrer*
GP name
Enrolled GP practice*
Contact email*
Referrer contact phone*
Important: Please ensure referrer contact phone number is included
Will the infusion be given in your own practice?

YesNo, I would like to refer to another clinic
Preferred Infusion Centre*
PATIENT DETAILS
Patient first name*
Patient last name*
NHI*
Date of Birth*

DayMonthYear
Gender*

MaleFemaleOther
Weeks gestation
If pregnant enter number of weeks/days (e.g 32.3)
Weight (kgs)*
Current weight or pre-pregnancy weight (to calculate correct dose)
Ethnicity*
Street address*
Suburb*
Best contact(s) for patient*
Contact phone number and person if not the patient's own number
Notes
Should be Empty:

IV IRON INFUSION REFERRAL

Specialist recommendation

Antenatal

Postnatal

Other patient criteria

REFERRAL DETAILS

PATIENT DETAILS