Iron Infusion Referral Form

PAT

Available Infusion Locations

Toowoomba - MO ID 408898TL – Phone 07 3088 8026
St Andrew’s Hospital. Suite 50. Building 2. 280 North St, Rockville.

Brisbane West (Sinnamon Park) -MO ID JC4073000C2 -Phone 07 3088 8026 
Sinnamon Park Medical Centre. 554 Seventeen Mile Rocks Road, Sinnamon Park.
Gold Coast (Gold Coast Specialist Rooms) - MO ID JC421500142–Phone 07 3088 8026  
145 Nerang St, Southport.

Patient Details

Available Infusion Locations
 Name: <PtFullName>	Medicare: <PtMCNo> <PtMCLine>  DVA: <PtDVANo>
DOB: <PtDoB>                  
Phone: <PtPhoneMob>  	          Email: <PtEmail>
Address: <PtStreet><PtCity> <PtState> <PtPostcode>

Referring Clinician Details

Clinical Details

Clinical details: <Clinical Notes?>

Name: <DrName>			Provider number: <DrProviderNo>
Practice Address: <Practice><UsrAddress> 
Phone:<UsrPhone>

Send referrals to
Fax: 07 4646 2439
Email: reception@tiic.clinic
Medical Objects (via listed MO ID for each location above)