POAC Radiology Request Form

POAC Radiology Request Form

(For hospital/ARRC/hospice use only)
Has this patient been to a MoH identified Covid 19 location of interest and/or required to self-isolate for 14 days? *

Yes No
Eligiblity confirmation *

I certify that this patient is eligible for public funded health services.
View MoH Eligibility Guide here
Patient domiciled DHB *

ADHB WDHB CMDHB
ACC number (where applicable)
Referring organisation *
Referring clinician *
Clinician registration number *
Referrer designation *

GP Hospital Nurse Practioner
Copy of report to GP (Name and Practice) *
This is a required field, please ensure correct details provided for reporting purposes
Referrer phone contact *
Referrer email
to receive copy of referral
Patient NHI *
Date of birth *

Day Month Year
Patient name *

First Name Last Name
Gender *

Male Female
Address *
Patient phone number (s) *
Please provide multiple phone numbers if available to ensure ease of contact
Ethnicity *
Urgency *

Within 24 hours 24-48 hours Within 1 week, pre-approved by POAC
Ultrasound Request

Abdomen - Upper (fasting required >4 hrs) Abdomen - Lower only Carotid Doppler DVT - Right leg DVT - Left Leg DVT - Right Arm DVT - Left Arm DVT - Bilateral Leg Musculoskeletal Pelvic Renal Scrotum
FASTING REQUIREMENTS: Nil food within at least four hours. Water or black sugar free tea/coffee only consumed. *

Next day scan - patient informed of fasting requirements Same day scan - patient has been fasting minimum four hours Not fasted or informed of requirements (scan will be scheduled once POAC has contacted patient)
Signs and symptoms of DVT, plus one of the following: *

Wells Score > 2 Elevated D-dimer Pregnancy Superficial thrombophlebitis
D-dimer result *
Body site
Name of endorsing specialist
where applicable
Clinical indication and medical history *
Form to be printed and signed, patient to take this form to appointment
Due to Covid 19 restrictions, this patient is unable to be scanned in primary care at a community radiology provider.

Please discuss with local DHB radiology or discuss with on-call hospital speciality for an appropriate management plan.

For more information visit the Ministry of Health website here

Thank you for your understanding and cooperation.
FOR POAC USE:
Appointment date and time

Day Month Year
Date Hour Minutes AM/PM Option
Radiology provider name
POAC comments
Signature:
Print and sign
Should be Empty: