ACUPUNCTURE REFERRAL


Patient Name : ____________________________________________________________

The above named patient is interested in receiving acupuncture.   

Please complete this form for the patient.

_____  No known restrictions or limitations for this patient


_____  This patient has the following restrictions or limitations :                            

____________________________________________________________________________

Patient diagnoses :_________________________________________________________
 
____________________________________________________________________________


Physician's Signature :_____________________________________________________

Print Physician,s Name :____________________________________________________

Clinic/Office Name & Address :______________________________________________

                              ______________________________________________

                              ______________________________________________

                              Phone :_______________________________________




Mail to :  Mary Anne Linder,C.AC.,R.N.,L.M.T.
           1200 Stanhope Drive
	   Columbus, Ohio 43221             
           Phone : 614-270-5044

Or, Fax to : 614-459-3767