Patient details
Patient name
*
Date of Birth
*
Address ( Please include Name of Suburb and Postcode)
*
Mobile Phone Number
*
Email address
*
Medicare Card Number
Medicare IRN number
Medicare care expiry date
Patient History
Diagnosis
*
No of treatments
*
Frequency of requested treatments
*
Special indications or instructions
Patient requiring 30+ grams Vitamin C - G6PD level
Patient requiring 30+ grams Vitamin C - eGFR level
Diabetes
*
Yes
No
Allergies
*
Referring Doctor Details
Doctor name
*
Address
*
Phone
Provider no
*
Treatment Plan - IV Nutrients
Vitamin C
7.5g
15g
22.5g
30g
Above 30g
IV B Dose
2ml
IV Zinc
5.1mg
IV MgS04
2.47g
IV Glutathione
500mg
1000mg
IV Ferinject
500mg
1000mg
NAD +
500mg
1000mg
No of dosages / notes
Treatment Plan - IM Injections
IM Vitamin D3
600,000 iu
300,000 iu
IM B-Dose Forte
2.5ml
IM Methyl-B12
10mg
No of Injections / notes
Patient medical history
Please upload blood results within the past 3 months including full blood count, Kidney and Liver Function Test.
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Please upload any additional patient information/medical history relevant to this order
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Doctor's signature & date
Signature of Doctor
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