POAC Funded Post Natal Long Acting Reversible Contraception (LARC)

POAC Funded Post Natal Long Acting Reversible Contraception (LARC) - Counties Manukau

For eligible Counties Manukau District residents
Date*

DayMonthYear
Date
I, the referrer, confirm the referred:*

is eligible for NZ public funded health services, ANDhas given birth in a CMH facility or miscarried within 12 weeks prior to referral date, ANDhas consented to this referral, ANDhas received appropriate counselling and provided with a patient information brochure,
Please advise if the following is applicable for the referred woman:

Maori or Pacific EthnicityQuintile 5Holds CSC CardAt risk of poor outcomes from unplanned pregnancyNon of these options apply
Patient has Community Service Card

YesNoDon't know
Patient is a beneficiary?*

YesNoDon't know
Referrer name*
Referrer email contact
To receive email confirmation
Referrer contact phone number(s)*
Patient NHI*
Date of birth*

DayMonthYear
Patient name*

First NameLast Name
Ethnicity*
Home address*
Patient contact phone number(s)*
Enrolled GP practice name*
Medical and Obstetric History*
Date of delivery*

DayMonthYear
Date
Gravida:*
Parity:*
Interim contraception method

AbstinenceDepo ProveraCondomsOral ContraceptionUnknown
Device of choice*
Ensure that the woman has been counseled and provided with a copy of the relevant brochure (www.poac.co.nz). Mirena is now funded, a $5 script fee will apply.
Preferred IUCD/Mirena Provider*
Preferred Jadelle Provider*
You have selected Family Planning as the preferred provider. A representative will call to schedule an appointment at the closest possible clinic.

Alternatively, you may call Family Planning on (09) 263 7600.
Additional notes/comments
Should be Empty:

POAC Funded Post Natal Long Acting Reversible Contraception (LARC) - Counties Manukau