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Please provide the most accurate date you are able to for medical conditions.
If you have seen any other medical specialists of have a physiotherapist, please add their details below (e.g. medical specialists and physiotherapist).
I give my consent to Dr David Agolley, or his 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 David Agolley, or his 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.