POAC Funded Zoledronate Infusion Subsidy

POAC Funded Zoledronate Infusion Subsidy Voucher

Application for subsidised zoledronate infusion for osteoporisis. The voucher for subsidy of $120 is valid for one month from the date of application. .
Date*

DayMonthYear
POAC funding criteria
Funding Criteria (all must be met)*

Patient resides in Counties Manukau DistrictCommunity Services Card HolderUnable to tolerate/unsuited to oral medication (must be documented)eGFR >35

Referrer details
Referring doctor*

First NameLast Name
Practice name*
Patient details
Patient name*

First NameLast Name
NHI*
Date of birth

DayMonthYear
Date
Ethnicity*
Address*
Where will patient have the infusion?

At the referring doctors clinicAt another infusion centre
Name of Infusion Centre patient will attend*
Should be Empty: