Orthopedic and Regenerative medicine referrals
Dr. Andy Singh
Holy Cross Family Medicine Clinic
Unit #101 – 10601 Southport Road SW
Calgary, AB, Canada
Phone: (403) 475-0111
Fax: (833) 527-9010
- Corticosteroid injections
- Non-steroidal injections
- Hyaluronic acid injections
- Platelet-rich plasma (PRP) therapy
- Prolotherapy
Reason for referral: _____________________________________________
Pertinent medical history: ________________________________________
Current medications: ____________________________________________
Relevant imaging/investigations attached if available.
Thank you for your assessment and recommendations.
Sincerely,
Referring Physician
Clinic: __________________________________
Phone: __________________________________
Fax: ____________________________________
Referrals
SAME DAY Iron Infusion Services! as long as you come before 4 pm!
Holy Cross Family Medicine Clinic
suite 101, 10601 South port Road SW, Calgary
Phone: 403 475- 0111
Fax: 833.527.9010
IRON INFUSION REFERRAL
Date: ______________________________________
Referring Provider Information
Referring Physician/NP: ______________________________________
Billing Number: _____________________________________________
Clinic Name: ________________________________________________
Phone: _____________________________________________________
Fax: _______________________________________________________
Patient Information
Patient Name: ______________________________________________
DOB: _______________________________________________________
PHN: _______________________________________________________
Phone Number: _____________________________________________
Reason for Referral
Requested Iron Infusion
Option 1 – Monoferric® (Ferric Derisomaltose)
☐ Monoferric 500 mg IV once — $400
☐ Monoferric 1000 mg IV once — $600
☐ Other dose: _________________________________________________
Option 2 – Venofer® (Iron Sucrose)
☐ Venofer 300 mg IV weekly × ______ doses, 1 vial $300, 2 vials $ 400
☐ Other dose: _________________________________________________
Service Price
Iron Infusion Administration Fee
$175 per infusion
Extended Monitoring (if required)
$50
Physician Assessment (non-AHCIP/uninsured)
$100
Supplies Fee
Included
Allergies / Previous Infusion Reactions