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:
Please advise if the following is applicable for the referred woman:
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
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