• POAC SERVICE REQUISITION

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  • Sorry, we are unable to proceed for the following reason:

    This option is only available where a level of care assessment has been completed and patient has been confirmed as requiring secure dementia level of care.

    Please call POAC to discuss (09) 535 7218

  • Please refer to ACC for home-based support services.  Use ACC705 form for DHB referral.


  • REFERRER INFORMATION



  • PATIENT DETAILS




  • CLINICAL HISTORY




  • SERVICES REQUIRED

  • Home Support Services


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  • Intravenous Therapy

  • - All medication is to be supplied

    - Daily dose medication only

    - Signed prescription and discharge summary (or clinical notes) to be faxed to POAC 09 535 7154 or attached to referral


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