Counties Manukau Urgent Obstetric Scan Request

OBSTETRIC RADIOLOGY REQUEST - URGENT
- Complete this form to request clinically urgent scans required within 24-48 hours of assessment. Routine ultrasounds should be arranged in the normal way to ensure those in high clinical need are prioritised.
- By completing this form the referrer confirms that the referred is eligible for maternity health services under Section 88, and is scheduled to birth in a Counties Manukau facility.
The following scan types are excluded, book community scan directly with provider:
- Suspected miscarriage
- Dating scans / viability (pre-20 weeks)
Date*

DayMonthYear
HourMinutesAM/PM Option
ECTOPIC PREGNANCY

Ectopic pregnancy high-risk cases MUST be scanned the same day as an acute presentation. If a same-day scan cannot be arranged, the patient must be referred to the Emergency Department for assessment. In cases of low suspicion or non-acute presentations requiring early pregnancy scans, monitor HCG levels and arrange a routine obstetric ultrasound. All cases should be discussed with the on-call SMO to ensure appropriate management and follow-up. This form should not be used on weekends, as ultrasound services are unavailable.

To refer now, click HERE
Clinical reason for urgent scan within 48 hours*
Clinical reason for urgent scan (clinically required within 24-48 hours). Note these requests undergo period audit for quality improvement purposes and to ensure priority is given to clinically appropriate cases.
I confirm that this patient would otherwise require acute hospital admission*

Yes, I would admit acutelyNo, acute admission is not required.
EDD*

DayMonthYear
Date
Weeks gestation *
(WW.D)
Scan type*
NOTE: DATING SCAN CO-PAYMENTS ARE NOT FUNDED. NUCHAL AND ANATOMY CO-PAYMENT FUNDED ONLY WITH VALID COMMUNITY SERVICES CARD NUMBER QUOTED ON THIS FORM AND ON RADIOLOGY REQUEST FORM
Name of endorsing SMO*
Clinical information*
Referrer designation*

LMC/MidwifeGeneral PracticeMiddlemore Secondary ServicesOther
Referring clinician*
Registration Number*
Referring practice/organisation*
Practice / Hospital
Referrer phone contact*
Mobile phone is preferred
Referrer email*
to receive copy of submission and direct contact for queries or feedback
LMC/Midwife name (if different to referrer)
Patient NHI*
Date of birth*

DayMonthYear
Date
Patient name*

First NameLast Name
Patient phone number*
Patient address*
Ethnicity*
Weeks gestation at time of referral*
Provider payment*

Patient can self-fundUnable to self-fund, co-payment will be fully funded by POAC
Funding voucher number (growth scans or anatomy/nuchal with CSC)*
If not already completed you can request a co-payment funding voucher here
Criteria for anatomy or nuchal

Community Services Card Holder (number to be provided at appointment)18 years or underNo CSC but at high needs, at risk of negative outcomeSpecial approval Te Whatu Ora Maternity Service Manager
Community Services Card Number
Previous scans completed at the following radiology provider(s)*
Additional notes
POAC Office Use

Booking details and comments
Radiology provider name
Appointment date and time

DayMonthYear
DateHourMinutesAM/PM Option
Radiology email
POAC Admin Notes
Status of referral (POAC internal use)

ApprovedDeclined, not eligibleOther
Unable to proceed:

Unfortunately, this referral is not eligible for a POAC-coordinated ultrasound. Please refer to a community radiology provider in a routine manner.
Should be Empty:

OBSTETRIC RADIOLOGY REQUEST - URGENT

POAC Office Use