ACC45 Registration Form M3 ACC45 Registration Details "*" indicates required fields 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 *protected email* prior to your appointment. Name* First Last Injury Details ACC Claim Number Date Of InjuryDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Approximate date if unknown Mechanism of injury (Describe what happened, please include the body part injured)* Have you had any imaging for this Injury X-ray Ultrasound MRI Other Have you seen any other medical practitioners regarding your injury? GP / Whitecross / DHB Another Physio Osteopath/Chiropractor/Acupunture Specialist Other Information Relevant to your claim Payment & ACC CoverI am aware of the ACC Surcharges and that payment is required at the end of each session. ACC =$35, Private =$70* Yes I acknowledge if my ACC is declined or invalid/expired I am personally liable for the treatment costs* Yes 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 *protected email* for cancelations and rebooking.* Yes Thank you for completing your ACC registration with M3 Clinic. We look forward to seeing you in the Clinic.
