ph: 09 535 7218

Fosfomycin

HOSPITAL PHARMACY:

AUCKLAND CITY HOSPITAL - OUTPATIENT PHARMACY
Phone: 09 307 8997
Fax: 09 307 8998
Level 5 (retail shopping area), ACH, Park Rd, Grafton

MIDDLEMORE HOSPITAL - INPATIENT PHARMACY
Phone: 09 276 0016 option 1
Fax: 09 276 0235Kidz First Entrance, 100 Hospital Rd, Otahuhu (ask security for directions)

NORTH SHORE HOSPITAL - OUTPATIENT PHARMACY
Phone: 09 486 8920 ext 2333
Fax: 09 486 8332
NSH, Main Foyer, 124 Shakespeare Rd, Milford
POAC Winter Coordination HBSS Referral

POAC Case Number
Referral Date:

DD
/
MM
/
YYYY
Referred By:*
Ward:*
Contact Phone:*

CLIENT INFORMATION

Last Name:*
First Name:*
DOB:*
NHI:*
Ethnicity:*
 European 
 Maori 
 Pacific 
 Asian 
 Other 
Home Address:
Home Phone:*
Mobile:
NOK Contact/Relationship:
NOK Phone Contact(s):
Reason for referral:*
Date of hospital admission:

DD
/
MM
/
YYYY
Planned hospital discharge date:

DD
/
MM
/
YYYY
Medical/Social history:*
Patient goals/rehabilitation plan (discussed with client):
Mobility
Level of cognition
*
Bladder Continent*
*
Bowel Continent*
*
Isolation Requirements*
*
Safety Risks*
Safety risks, isolation requirements, hazards at client's home:
GP Name:*
GP Phone:*
GP Practice:*

SERVICES REQUIRED:

Tasks
Toileting
 Select Required 
Dressing
 Select Required 
Meal Preparation
 Select Required 
Transfers/Turning Hoist
 Select Required 
Showering/Bed Bath
 Select Required 
Heavy Household Tasks
 Select Required 
Number of weeks services required:

(Patient will be reviewed at 2 weeks and assessed for ongoing requirements)
*
 1 week 
 2 weeks 
 3 weeks 
 4 weeks 
 5 weeks 
 6 weeks (automatic for surgical patients) 
Is there any urgent need immediately following discharge?
First Visit Required:*

DD
/
MM
/
YYYY
Number of visits per day:*
Preferred time of visit:
Length of each visit (hours):*
Special requirements (diet/cultural/communication)
Referrals made to other services
(consider DN, OT, NASC, equipment)
POAC Winter Coordination HBSS Referral

POAC Case Number
Referral Date:

DD
/
MM
/
YYYY
Referred By:*
Ward:*
Contact Phone:*

CLIENT INFORMATION

Last Name:*
First Name:*
DOB:*
NHI:*
Ethnicity:*
 European 
 Maori 
 Pacific 
 Asian 
 Other 
Home Address:
Home Phone:*
Mobile:
NOK Contact/Relationship:
NOK Phone Contact(s):
Reason for referral:*
Date of hospital admission:

DD
/
MM
/
YYYY
Planned hospital discharge date:

DD
/
MM
/
YYYY
Medical/Social history:*
Patient goals/rehabilitation plan (discussed with client):
Mobility
Level of cognition
*
Bladder Continent*
*
Bowel Continent*
*
Isolation Requirements*
*
Safety Risks*
Safety risks, isolation requirements, hazards at client's home:
GP Name:*
GP Phone:*
GP Practice:*

SERVICES REQUIRED:

Tasks
Toileting
 Select Required 
Dressing
 Select Required 
Meal Preparation
 Select Required 
Transfers/Turning Hoist
 Select Required 
Showering/Bed Bath
 Select Required 
Heavy Household Tasks
 Select Required 
Number of weeks services required:

(Patient will be reviewed at 2 weeks and assessed for ongoing requirements)
*
 1 week 
 2 weeks 
 3 weeks 
 4 weeks 
 5 weeks 
 6 weeks (automatic for surgical patients) 
Is there any urgent need immediately following discharge?
First Visit Required:*

DD
/
MM
/
YYYY
Number of visits per day:*
Preferred time of visit:
Length of each visit (hours):*
Special requirements (diet/cultural/communication)
Referrals made to other services
(consider DN, OT, NASC, equipment)
 

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