POAC Referral Funding Request
Submit the hospital referral details for Pivmecillinam UTI funding and receive your POAC Case Number confirmation.
Hospital Referring
*
Please Select
Auckland City Hospital
Middlemore Hospital
North Shore Hospital
Waitakere Hospital
Other
Date of Prescribing
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
NHI
*
Patient First Name
*
Patient Last Name
*
Referrer Name
*
Referrer Email
*
Submit Referral
Should be Empty: