Notification Regarding Evaluation

Notification Form Regarding Evaluation of Patient by Physician

Pursuant to the requirements of Section 205.301 of the Texas Occupations Code, governing the practice of acupuncture
I Patient's Name* am notifying Ronald Guillermo Banuelos, L.Ac. of the following:
I have been evaluated by a physician or dentist for the condition being treated within twelve (12) months before the acupuncture is performed.

YesNo
I have received a referral from a chiropractor within the last 30 days for acupuncture.

YesNo
If yes, the date of the referral is:
DD/MM/YYY
If yes, the most recent date of chiropractic treatment prior to acupuncture treatment is:
DD/MM/YYY
After being referred by a chiropractor, if after 60 days or 20 treatments, whichever comes first, no substatial improvement occurs in the conditions being treated, I understand that the acupuncturist is required to refer me to a physician. It is my responsibility and choice to follow this advice.
Signature (or Parent/Guardian Signature)

Clear

Notification Form Regarding Evaluation of Patient by Physician