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Physiosouth ACC 45 Form

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Section 4 - ACC45
Client Name*
Phone Number*

Mobile/ Home phone number for contacting
Is this an ACC Injury*
Date of Injury*

Day
Month
Year
Time of Injury*

Please specify if am or pm.
Location*

(e.g Selwyn, Christchurch, Auckland)
Place of Injury*

(e.g. Home, School, Road)
How did the injury happen?*
Describe what happened and which part of your body has been affected.
Occupation*
Have you been or will be off work for more than 2 weeks due to injury?*
Please tick those that apply
- I am in paid employment
- I am self-employed
- I own/part-own the company in which I work
- I am not in paid employment
Work Intensity
- Sedentary
- Light
- Medium
- Heavy
- Very Heavy
Did the accident occur at work?
What is the name of the business you are employed by/own?
What is the address of the business you are employed by/ own?
Is this injury as a result of a motor vehicle accident?
Is this injury a result of a sport accident?
Type of sport
Acc Declaration
I declare – The information I have given about this claim is true and correct and that I have not withheld any information.

I authorise – The treatment provider to lodge the claim for me. The collection and release of any information about me to the extent that this is needed to prevent future injuries, determine cover and/or assess my entitlement to compensation, rehabilitation assistance, medical treatment and/or the appropriate level of care and personal attention I should receive. ACC to contact anyone who holds relevant information, including any external agencies or service providers (such as medical practitioners, specialists, New Zealand Police and Treatment Providers, IRD, WINZ, Assessment Agencies, employers and witnesses to the accident.
I have read and understand the information above and by ticking this box I give my full consent*
- Yes, I give my full consent
Signed*

Type your full name (if under 16 must be signed by parent/guardian)
Date*

Day
Month
Year
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About Us

Our Repair, Perform and Thrive philosophy supports our approach to keep you active in the areas you love the most. We help you overcome injuries and illness, increase your capabilities and create the conditions for enhanced wellbeing.

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