Acupuncture & Natural Therapies/ Melanie Myers

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 --------------------------------------------------------------------------------------------------------------------- (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.