POAC Radiology Request Form

POAC Radiology Request Form

(For hospital/ARRC/hospice use only)
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/Pelvis Carotid Doppler DVT - Right leg DVT - Left Leg DVT - Right Arm DVT - Left Arm DVT - Bilateral Leg Musculoskeletal Pelvic Renal Scrotum Soft Tissue
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
Signs and symptoms of DVT, plus one of the following: *

Wells Score > 2 Elevated D-dimer Pregnancy Superficial thrombophlebitis
D-dimer result *
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: