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Recommendation for Exam

Fredericksburg Acupuncture Specialist

Recommendation by Examination

I, Dr. Rev. Melanie Myers,Licensed Acupuncturist, recommend to you


______________________________________________________
(patient)
that you be examined by a physician regarding the condition for which you are seeking acupuncture treatment.



I understand this recommendation.


_____________________________ ______________________________
Patient Date


Virginia law requires that I give this form to you if I do not have written evidence that you have received a diagnostic exam in the last six months from a licensed practitioner of medicine, osteopathy, chiropractic or podiatry regarding the condition for which you are seeking treatment. (Code of Virginia 54.1-2956.9, 18 VAC 85-110-10).


_____________________________ ______________________________
Acupuncturist Date


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(On a separate sheet)

Instructions to Licensed Acupuncturist:

The patient must sign and date the form.
Make a copy of this form and retain the original in the patients chart. Give a copy of the signed form to the patient.
If the patient does not understand English, make sure the form is translated to the patient or provide the form in the patients language.

This form is required by Virginia State Law. It is a recommendation only.

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2007 Melanie Myers, All rights reserved