FROM THE HYPNOTIST TO THE DOCTOR:Your patient: Name of Patient* Age: Age of Patient* Phone: Patient's Phone Number* is requesting instructions in self-hypnosis to help with the following:Areas in which the patient wishes to address (i.e stop smoking, weight management,etc.)*Since I require a physician's referral in such cases, I would appreciate your signature below, indicating your approval. Should you have any questions please feel free to call me at: 1-888-880-4933. Thank you in advance for your attention to this matter Shawna SteilenCertified Hypnotistwww.life-changinghypnosis.com
FOR THE DOCTOR TO RETURN TO THE HYPNOTIST:I have examined and evaluated the patient named above and see no contraindication to the use of self-hypnosis in this case.Additional Comments:__________________________________________________________________________________________________________________________________________________________________________________________Physician's Signature:___________________________________________Date:______________________Print Doctor's Name: _______________________________________________________________________Office Street Address: _____________________________________________________________________Office City: ___________________________________State:_________________Zip:___________________Office Phone: _________________________________Office Fax: __________________________________