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DeerFields Clinic - IV Therapy Referral Form

Requested Delegated IV’s:

Patient History

Recent Physical Exam Completed including CV and Respiratory
Yes
No
Screening Blood Work Completed (CBC, Kidney Function, LFTs, Electrolytes, Ferritin)
Yes
No

*Please Attach or Fax all lab work with referral

Other Pertinent Information:

Thank you! We will contact the patient directly once this form ahs been received.


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