POAC Ferinject Infusion Referral

Date

DayMonthYear
Date
POAC FERINJECT INFUSION REFERRAL

Referral for Auckland Region POAC funded community Ferinject Infusion
The patient must be eligible for publicly funded primary health care. This is not included in maternity funding package. Please check this before referring.

See Health NZ guide to eligibility HERE

For queries, email claims@poac.co.nz
Patient is aged 14 years or overPatient (or caregiver) has been informed and consents to referralEligible for Public Health FundingBlood tests completed within 4 weeks (3 months for renal patients) of referral
NZ resident or citizen (including those from the Cook Islands, Niue or Tokelau)Two years continuous working visaReciprocal agreement with UK, Australia
Patient Residence District*
CLINICAL INFORMATION

Note: Special Authority will be required for supply of medication
Patient has had two or more iron infusions in preceding 6 monthsRisk of hypophosphataemia e.g. BMI < 18, poor nutrition, chronic diarrhoeaNone of the above applies
Phosphate*
Phosphate MUST be tested prior to referring for this patient
Anaemia and ferritin ≤ 20 mcg/LAnaemia and ferritin 20–50 mcg/L AND CRP ≥ 5 mg/LPatient has chronic inflammatory disease with symptoms of anaemiaSpecialist recommendation for treatment of iron deficiency anaemia
Oral iron treatment has proven ineffectiveOral iron treatment has resulted in dose-limiting intoleranceRapid correction of anaemia is requiredPatient has symptomatic heart failure, chronic kidney disease stage 3 or more or active inflammatory bowel disease and a trial of oral iron is unlikely to be effective
Ferritin
Haemoglobin
CRP
YesNo
EDD*

DayMonthYear
Date
Weeks gestation
Number of weeks/days (e.g 32.3)
>37 weeks, with SMO endorsementFirst Trimester Pregnancy, with SMO endorsementHb <70 AND >34 weeks gestation, with SMO endorsementNo obstetric risks
Name of endorsing specialist*
Must be internal medicine physician, obstetrician, gynaecologist or anaesthetist
REFERRAL DETAILS
Date *

DayMonthYear
Date
General Practice/Urgent CareHospitalRenal ServiceObstetricsMidwife/LMCOther
Name of referrer*
Referrer email*
Referrer contact phone*
Important: Please ensure referrer contact phone number is included
Enrolled GP practice*
GP name
If different to referrer
YesNo, I would like to refer to another clinic
Preferred Infusion Centre*
PATIENT DETAILS
Patient first name*
Patient last name*
NHI*
Date*

DayMonthYear
Date
MaleFemale
Ethnicity*
Street address*
Suburb*
Best contact(s) for patient*
Contact phone number and person if not the patient's own number
Notes
Should be Empty:

POAC FERINJECT INFUSION REFERRAL

CLINICAL INFORMATION

REFERRAL DETAILS

PATIENT DETAILS