CMH Clinically Urgent Scan Request

CMH POAC URGENT MATERNITY SCAN REQUEST

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.
Eligiblity Confirmation *

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

LMC/Midwife General Practice Secondary Services
Referrer phone contact *
Referrer email *
to receive copy of submission
Midwife name *
Midwife 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
Weeks gestation *
EDD *

Day Month Year
Date
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 *
Previous scans completed at the following radiology provider(s) *
Additional notes
Upload a copy of radiology form (optional)

Browse Files
A radiology form must be provided or the scan will not be completed. It is helpful if this can be sent in advance. You can attach the radiology request form or email a copy to referral@poac.co.nz Cancel of
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:

CMH POAC URGENT MATERNITY SCAN REQUEST