ACC Care | Self-Refer with Nurse Maude

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If you require urgent medical attention, please call 111 immediately. This form is not monitored for emergencies and should not be used for urgent care.

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This form is for people in Canterbury who have had an accident and need wound care, continence care, or stomal care funded by ACC. You can use this form to refer yourself directly to Nurse Maude for non-urgent care, either at home or at our clinic.

Please note that this service is only available within the Canterbury region.

Who is this referral for?

Myself

Someone else (patient, client, family member, friend, colleague for example).

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Referrer Details

Please complete this section only if you are referring on behalf of someone else.

Full Name

Relationship to the person being referred

Organisation (if applicable)

Phone number

Email Address

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Details of the person who requires medical care.

First Name

Surname

Date of birth (if known)

NHI Number (if known)

Gender:

Phone number

Email Address

Home Address

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Referral Details

Reason for referral

Have you notified ACC Already?

Yes

No

If you have an ACC Claim number, please include it here:

Please provide any other information you feel would be useful.

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Declaration

Opt-In

I confirm that I have read and understood Nurse Maude’s Privacy Statement and consent to the collection and use of my information as outlined.

ACC Self Referral

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