CMH Clinically Urgent Scan Request

OBSTETRIC RADIOLOGY REQUEST - URGENT

Due to the high demand of maternity scanning, this request form is only to be used for clinically urgent scans, required within 24-48 hour period. See criteria below.
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 *

This patient is eligible for maternity health funding and is scheduled to birth in a CMH facility
Referrer name *
Organisation name *
Practice / Hospital
Referrer designation *

LMC/Midwife General Practice Secondary Services
Referrer phone contact *
Referrer email *
to receive copy of submission
LMC/Midwife Details
LMC/Midwife name *
Contact phone *
Patient NHI *
Date of birth *

Day Month Year
Patient name *

First Name Last Name
Patient phone number *
Patient address *
Ethnicity *
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
EDD *

Day Month Year
Weeks gestation *
Clinical reason for urgent scan *
Clinical information *
Provider payment *

Patient can self-fund Unable to self-fund, co-payment will be fully funded by POAC
Funding voucher number *
Community Services Card Number *
Previous scans completed at the following radiology provider(s) *
Additional notes
Upload a copy of radiology form (optional)

Browse Files
IMPORTANT: A radiology request form must be provided prior to booking. You can attach the radiology request form or email a copy to referral@poac.co.nz Cancel of
Due to Covid 19 restrictions, this patient is unable to be scanned in primary care at a community radiology provider. Please discuss with DHB radiology or on-call obstetric team for an appropriate management plan.

For more information visit the Ministry of Health website here

Thank you for your understanding and cooperation.
POAC Office Use

Booking details confirmed
Radiology provider name
Appointment date and time

Day Month Year
Date Hour Minutes AM/PM Option
Should be Empty:

OBSTETRIC RADIOLOGY REQUEST - URGENT

LMC/Midwife Details

POAC Office Use