Beijing Acupuncture & Healing Center

 

Joseph J. Zhuang    Reg. Ac. Dipl. Ac. & CH

                Shufeng   Ding         Reg. Ac. Dipl. Ac. & CH

 

 

2181 W. Dublin-Granville Road

Worthington, OH 43085

 

Phone: 614-537-2759 or 614-537-2759

Fax: 614-659-9798

 

Referral for Acupuncture Treatment

 

Date:  _________/_________/________

 

Patientí»s Name: ______________________________________

 

Primary Diagnosis: ___________________________________

 

Secondary Diagnosis: _________________________________

 

Instructions/ Precautions: _____________________________

 

Referring Physician: __________________________________

 

Physician Address: ___________________________________

 

                                 ____________________________________

 

Physician Phone: _____________________________________

 

Physician Signature: __________________________________