Referral Form
 

Acupuncture by Chen

4610 Sawmill Rd. Columbus, OH 43220
Ph:614-538-0983, Fx:614-538-0989

Shixi Chen, OMD (China)
Dipl. Ac. (NCCAOM)


Physician's Referral for Acupuncture
Treatments

Patient's Name

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Condition to be treated

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Intervals at which the patient's progress is reported of referring physician___________________________

Restrictions, if any, placed on proposed treatment

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Name of referring physician

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Address

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Phone number for consultation during normal business hours

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After normal business hours

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Signature