Health Summary Request Form

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Date of Birth

Your Email address

Your Health Professional’s Email address

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Please fill in this form to request a health summary be forwarded to your nominated health provider.

Dr Gull Herzberg, Integrative Medical Practitioner

Southern Cross Medical Specialists, ph: 6658 4000
Bellingen Healing Centre, ph: 6655 0000
Bellingen Youth Hub Clinic, ph: 6655 0381 or 0412 361 562