Acupuncture Notification Form

Acupuncture Notification Form Regarding Evaluation of Patient by Physician

Acupuncture Notification Form Regarding Evaluation of Patient by Physician

In the state of Texas, acupuncture and Oriental medicine are not considered “primary health care.” As a result, Myo Acupuncture is required to have you respond to the following statements before you may be treated. Please be advised that we will not be permitted to treat you with acupuncture if your response to all of these statements is no.

(Pursuant to the requirements of 22 TAC §183.7 of the Texas State Board of Acupuncture Examiners’ rules relating to Scope of Practice and Tex. Occ. Code Ann., §205.351, governing the practice of acupuncture.)

Myo Acupuncture is not responsible for untrue statements made by patients.

I have been evaluated by a physician or dentist for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.
I have received a referral from my chiropractor within the last 30 days for acupuncture. (After being referred by a chiropractor, if after two months or 20 treatments, whichever comes first, no substantial improvement occurs in the condition being treated, I understand that the acupuncturist is required to refer me to a physician. It is my responsibility and choice whether to follow this advice.)
I have not been evaluated by a physician or dentist for the condition being treated, nor have I received a referral from a chiropractor, but I seek treatment for symptoms related to one or more of the following conditions:
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