ACC45 Registration Form

M3 ACC45 Registration Details

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Welcome to M3 Clinic.
We require you're ACC information prior to your appointment. Please complete the below form so we can gather your claim details.
If you have lodged an ACC claim for this injury and prefer to give your ACC details over the phone please call 094388207 or email a copy of your ACC45 document to prior to your appointment.

Injury Details
Date Of Injury
Have you had any imaging for this Injury
Have you seen any other medical practitioners regarding your injury?

Payment & ACC Cover
I am aware of the ACC Surcharges and that payment is required at the end of each session. ACC =$40, Private =$75*
I acknowledge if my ACC is declined or invalid/expired I am personally liable for the treatment costs*
I acknowledge there is a No Show / Late cancellation policy of for failing to attend my scheduled appointment. Please contract the clinic on 094388207 or for cancelations and rebooking.*
Thank you for completing your ACC registration with M3 Clinic. We look forward to seeing you in the Clinic.