Referral Form

Carrie Craddock Faries, Rac

Delaware Acupuncture Clinic                                  

593 Sunbury Road                                                                

Delaware, Ohio  43015

 

(740)816-2571                                                   www.delcoacupuncture.com

(740)362-1293    fax                                            carrie@delcoacupuncture.com

 

Acupuncture Referral

 

Date: ____/______/_________

 

Patient Name:  _________________________________________________                                                                           

Primary Diagnosis:______________________________________________

 

Secondary Diagnosis:____________________________________________

 

Instructions/Precautions:_________________________________________

 

Current Treatment:______________________________________________

 

Re-check with Doctor:       ________ wks

 

 

Referring Physician: _____________________________________________

 

Physician Address:  _____________________________________________

 

Physician Phone:     _________________________________

 

 

Physician Signature:  _________________________________
Text Box: It is the commitment of the Delaware Acupuncture Clinic to work synergistically with a patient’s primary care physician and other healthcare providers to provide optimal care for patients. In Ohio, acupuncturists must have a referral from a medical doctor to obtain acupuncture services and I look forward to building long standing relationships with physicians. Carrie Craddock Faries, Rac Text Box: Delaware Acupuncture Clinic Carrie Craddock Faries, Rac