Required Before Your Appointment
Please read the following disclaimer carefully and sign below to confirm your understanding before proceeding with your iron infusion.
I have been referred for intravenous iron infusion to treat my diagnosed iron deficiency anemia (IDA). I understand that iron infusion is a treatment intended to help replenish iron stores and improve symptoms associated with anemia, but it does not address or diagnose the underlying cause of my iron deficiency.
My lab results indicate severe iron deficiency anemia, including low hematocrit, low red blood cell count (RBCs), and low mean corpuscular volume (MCV). These findings can be associated with serious underlying medical conditions, including but not limited to gastrointestinal bleeding (such as from ulcers, polyps, cancer, or other sources), heavy menstrual bleeding, malabsorption disorders, nutritional deficiencies, chronic disease, or other significant pathology. Failure to promptly investigate the cause of severe IDA may lead to delayed diagnosis of serious illness, ongoing blood loss, worsening anemia, or other complications.
I have been strongly advised to immediately follow up with my primary care physician (PCP) or an appropriate specialist (such as gastroenterology or hematology) for a comprehensive evaluation to determine and treat the underlying cause of my severe IDA.
I understand that if I experience worsening symptoms (such as severe fatigue, shortness of breath, chest pain, dizziness, black/tarry stools, vomiting blood, or other concerning changes), I should seek emergency medical care without delay.
The iron infusion provider and staff are not assuming responsibility for the ongoing management, diagnostic workup, or long-term care of my anemia or its underlying etiology. This infusion is a supportive treatment only.
I acknowledge that I have been informed of the need for prompt follow-up and diagnostic evaluation. I agree that the iron infusion provider, its staff, and affiliated entities shall not be held liable for any complications, injuries, progression of disease, or adverse outcomes that may arise from my failure to follow these recommendations or from any delay in investigating the underlying cause of my severe IDA.
By signing below, I confirm that I have read and understand this disclaimer, I have had the opportunity to ask questions, and I voluntarily proceed with the iron infusion while accepting full responsibility for obtaining appropriate follow-up care.