Ultrasound referral
135 Don Street, Invercargill · 3/24 Dungarvon Street, Wanaka · office@southernultrasound.co.nz
Patient details
Name
Address
Phone
Date of birth
NHI
Ultrasound required
ACC / appointment
ACC No
Appointment date
Time
Pregnancy scans (clinical codes - as per Section 88)
LMP / unsure
EDD / by scan
Clinical information
Referrer
Referrer
Copies to
Signed (referrer)
Email/EDI
Provider details
NZMC/MC#
Phone
Date