POAC Radiology Request Form

POAC Radiology Request Form

Auckland | Waitematā | Counties Manukau
IMPORTANT NOTE REGARDING POAC SCANS:

POAC provides coordination and funding of radiology services required within 24-48 hours, as well as supporting coordination of pelvic ultrasound under the AUB pathway criteria. Non-urgent scans should be referred via Access to Diagnostics or e-Referral.

Review National Community Referred Radiology Criteria HERE

Maternity:

This is for clinically urgent scans only (required within 24-48 hours) for the included indications below:
- Suspected Ectopic Pregnancy (with named specialist endorsement)
- Retained products of conception
Excluded:
- Suspected miscarriage
- Dating scans
- Routine obstetric scans
Counties Manukau provides a separate service to coordinate access to clinically urgent obstetric scans. Specific clinical criteria apply, refer here

Pelvic Ultrasounds:

Please note there is limited access to community pelvic ultrasound, please consider alternative management prior to submitting this referral. Many presentations of pelvic pain may not require any acute imaging.
- Ensure to refer to the POAC pelvic ultrasound funding policy here. All other requests will be returned to the referring clinician.
- POAC facilitates access to ultrasound under the Abnormal Uterine / Postmenopausal Bleeding pathways for Counties Manukau residents only. Auckland and Waitemata should be submitted via e-Referral or ATD. See details here.
Date

DayMonthYear
Date
I certify that this patient is eligible for public funded health services.
Patient is immobile and will require assistance with transfers (unable to self transfer from wheelchair to bed). Community radiology is not suitable, please refer to hospital radiology.Wheelchair, able to self-transferNo mobility concerns
Community radiology is not suitable, please refer to hospital radiology.
View MoH Eligibility Guide here
AucklandWaitemataCounties Manukau
ACC number (where applicable)
Referring organisation*
Referring clinician*
Clinician registration number*
General PracticeUrgent Care ClinicEmergency DepartmentHospiceHospitalOther
I confirmer, as requestor, that I will be responsible for reviewing the radiology report and follow up with the patient, OR will contact the patient's GP to handover directlyI request that the patient's enrolled GP, as named below, review the report and provide any required follow up
Copy of report to GP for review (Name and Practice)*
This is a required field, please ensure correct details provided for reporting purposes
Referrer phone contact (mobile preferred)*
Mobile phone number is preferred where possible
Referrer phone contact notes
Referrer email*
Patient NHI*
Date of birth*

DayMonthYear
Patient name*

First NameLast Name
MaleFemale
Patient Residential Address*
Patient phone number (s)*
Please provide multiple phone numbers if available to ensure ease of contact
Ethnicity*
Abdomen - Upper - ultrasoundBreast ultrasound - mastitisCarotid doppler ultrasoundDVT - right leg - ultrasoundDVT - left leg - ultrasoundDVT - right arm - ultrasoundDVT - left arm - ultrasoundDVT - bilateral leg - ultrasound (with haematology endorsement)Pelvic ultrasound (acute)Pelvic ultrasound AUB (Counties Manukau residents, with criteria met for AUB/PMB pathway. Negative pregnancy)Renal ultrasoundScrotum ultrasound - low risk torsion (endorsed urology)Scrotum ultrasound - suspected malignancySoft tissue ultrasound - ?foreign bodyCT KUBCT Head (endorsed, non-ACC/injury)Xray - ChestXray - AbdomenXray Musculoskeletal (specify site)Other
Retained products of conception (RPOC)Suspected ectopic pregnancy - with gynae endorsementSuspected pelvic collection - not responding to PID treatment OR suspected adnexal massAcute ongoing pain following ED presentation (with negative pregnancy test)Lost IUCD strings WITH significant painOvarian Cyst Accident (ongoing pain)
CT Other
Indicate scan type, include if contrast required
Next day scan - patient informed of fasting requirementsSame day scan - patient has been fasting minimum four hoursNot fasted or informed of requirements (scan will be scheduled once POAC has contacted patient)
Within 24 hoursWithin 48 hours
CT scan requests:
- All CT requests are non-contrast unless specified
- Ensure the possibility of pregnancy is excluded
- Confirm all clinical red-flags are excluded prior to referring
The referrer confirms patient 1. resides within the Counties Manukau district 2. meets all clinical criteria for funding and 3. patient is NOT pregnant
PregnancySuperficial thrombophlebitisUpper limbWells Score 2 or moreElevated D-dimer
Confirmed negativeNot applicable (no chance of pregnancy, not within child bearing age)
D-dimer result*
Body site
Name of endorsing specialist
where applicable
Clinical indication and medical history*
Language barrier with no support personTransport (uber/taxi) requiredWheelchair bound - must be able to transfer to bed. Community scan is not suitable for immobile patients, please refer to hospital radiology
Form to be printed and signed, patient to take this form to appointment
FOR POAC USE:
Appointment date and time

DayMonthYear
DateHourMinutesAM/PM Option
Radiology provider name
POAC comments
Signature:
Print and sign
Should be Empty: