07 3839 0280
Please note: items marked * indicate mandatory fields.
If there are any other specialists that require clinical information, please fill the information below.
I give my consent to Dr Trevor Gervais, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care.
I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Trevor Gervais, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010.
For more information view our Patient Information Privacy Statement on this website.