POAC Radiology Request Form - 24 Dec 2024-5 Jan 2025

POAC Radiology Request Form - Updated for Christmas Holiday Period 24 December 2024 - 5 January 2025

Auckland, Counties Manukau and Waitemata Districts
Clinical Guidance for Referring Clinicians: Ultrasound (USS) and CT Investigations (24 December 2024 – 5 January 2025)

Radiology Request Form Availability
The normal POAC radiology request form will be available as usual from Saturday, 4 January 2025, for scheduling appointments starting Monday, 6 January 2025.

Unavailable Dates for CT and USS
CT and USS services will be unavailable on the following dates:

Tuesday, 24 December (from 12 pm)
Wednesday, 25 December
Thursday, 26 December
Saturday, 28 December
Sunday, 29 December
Wednesday, 1 January
Thursday, 2 January
Saturday, 4 January
Sunday, 5 January

Limited Appointment Availability
Some sites will be open with limited appointments on the following dates:

Friday, 27 December
Monday, 30 December
Tuesday, 31 December
Friday, 3 January

For available appointments on these dates, please contact the following providers to confirm available options:

Canopy Imaging: (09) 486 1659
Auckland Radiology: (09) 529 4850
Mercy Radiology: 0800 497 297
Astra Radiology: (09) 520 9550

Note: Providers are open limited hours and exclude public holidays/weekends.

Referral Instructions
Refer Online: Submit referrals via the online POAC radiology request system.
Appointment Confirmation: Ensure the patient or a clinic team member confirms the appointment within the required timeframe.
Management Plan: Establish an appropriate management plan for situations where appointments are delayed or scans are unavailable.

Ultrasound and CT available during the holiday period:

DVT Ultrasound: Normal criteria, unilateral limb only will be available. Upper limb may not be available by all sonographers.

Pelvic Ultrasound for Ectopic Pregnancy:

Referrals must be endorsed by a gynaecology consultant. If the scan cannot be completed on the same day, the patient must be referred to ED.

Upper Abdominal Ultrasound (severe RUQ pain):

Ensure the patient is advised of fasting requirements before the scan.

CT KUB: Normal criteria for renal colic. Non-contrast.

CT Head (acute and non-injury related): Discuss neurology, acute scans only to avoid same day ED

For all other conditions, manage clinically with input from hospital specialists where required.

Complete referral form below, thank you for your understanding and we wish you happy holidays.
Date

DayMonthYear
Date
Radiology Request Type

Abdomen upper ultrasound for acute RUQ painDVT - right leg - ultrasoundDVT - left leg - ultrasoundDVT - right arm - ultrasoundDVT - left arm - ultrasoundPelvic ultrasound - suspected ectopic pregnancy (with endorsement)Pelvic ultrasound AUB (Counties Manukau residents, with criteria met for AUB/PMB pathway. Negative pregnancy)CT KUBCT head (acute non-injury)Xray - ChestXray - AbdomenXray Musculoskeletal (specify site)
CT scan requests:
- All CT requests are non-contrast unless specified
- Ensure the possibility of pregnancy is excluded
- Confirm all clinical red-flags are excluded prior to referring
Abnormal Uterine Bleeding (AUB) Pathway Criteria*

The referrer confirms patient 1. resides within the Counties Manukau district 2. meets all clinical criteria for funding and 3. patient is NOT pregnant 4. Appointments are scheduled within 3-4 week period
Signs and symptoms of DVT, plus one of the following:*

PregnancySuperficial thrombophlebitisUpper limbWells Score 2 or moreElevated D-dimer
D-dimer result*
Body site
Name of endorsing specialist
where applicable
Clinical indication and medical history*
Eligibility confirmation*

I certify that this patient is eligible for public funded health services.
Patient domiciled District*

AucklandWaitemataCounties Manukau
ACC number (where applicable)
Referring organisation*
Referring clinician*
Clinician registration number*
Referred by*

General PracticeUrgent Care ClinicEmergency DepartmentHospiceHospitalOther
Radiology reporting and follow up

I confirmer, as requestor, that I will be responsible for reviewing the radiology report and follow up with the patient, OR will contact the patient's GP to handover directlyI request that the patient's enrolled GP, as named below, review the report and provide any required follow up
Copy of report to GP for review (Name and Practice)*
This is a required field, please ensure correct details provided for reporting purposes
Referrer phone contact (mobile preferred)*
Mobile phone number is preferred where possible
Referrer phone contact notes
Referrer email*
Patient NHI*
Date of birth*

DayMonthYear
Patient name*

First NameLast Name
Gender*

MaleFemale
Address*
Current address at time of referral
Patient phone number (s)*
Please provide multiple phone numbers if available to ensure ease of contact
Ethnicity*
Form to be printed and signed, patient to take this form to appointment
Should be Empty:

POAC Radiology Request Form - Updated for Christmas Holiday Period 24 December 2024 - 5 January 2025