Pelvic Ultrasound - Abnormal Uterine Bleeding (Counties Manukau)

POAC RADIOLOGY REQUEST

Pelvic Ultrasound for Abnormal Uterine Bleeding (AUB) or Post Menopausal Bleeding (PMB) for Counties Manukau Residents
IMPORTANT – COUNTIES MANUKAU PATIENTS ONLY

This form is for Abnormal Uterine Bleeding (AUB) pelvic ultrasound requests for Counties Manukau patients only.

Please check the POAC AUB information at www.poac.co.nz/aub and Auckland Region HealthPathways before submitting.

Auckland and Waitematā patients: Please do not use this form. Submit requests via eReferral or Access to Diagnostics.
Referral date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Pelvic Ultrasound
Clinical information
Date of last menstrual cycle

DayMonthYear
2 digit day, 2 digit month, 4 digit yearWhere relevant and known
Referring practice/organisation
Practice / Hospital name
Referring clinician name
Registration number
Referrer phone contact
Mobile phone is preferred
Referrer email
To receive copy of submission and direct contact for queries or feedback
Patient NHI
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Patient name

First NameLast Name
Patient phone number
Patient email
Optional
Patient address
Ethnicity
Additional notes including access barriers, timing, location of booking.
Note that funded transportation is not included in AUB Pathway referred patients
POAC Office Use

Booking details and comments
Radiology provider name
Appointment date and time

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
Radiology Email Address
POAC Admin Notes
Should be Empty:

POAC RADIOLOGY REQUEST

POAC Office Use