Referral for Acupuncture

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for referring your patient to ECHO Acupuncture. To ensure the highest quality of care and maintain compliance with HIPAA regulations, this form is designed to securely collect the necessary patient information and relevant clinical details. All information shared will be handled with strict confidentiality and used solely for the purpose of providing coordinated, effective care.

If you have any questions or require additional information, feel free to contact us directly.

Reason for referral

I am a western provider (e.g. MD, DO, PA, NP, DC, PT) referring for acupuncture

I am an acupuncturist referring someone that I do not intend to see in my own clinic

I am an acupuncturist referring for adjunctive care (e.g. for community acupuncture)

Clear selection

Your Name and Practitioner Type (e.g. Liz Allen, DO) *

NPI (for insurance-required referrals)

Clinic or Hospital Name

Your Email *

Patient's First Name and Last Initial (e.g. Kay B.) *

Patient's Email *

Reason for Referral (e.g. neck pain) *

Comments

Please include any other information that you think would be helpful here.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms