Figure 2: 22 TAC §183.10(a)(11)

Optional Form to be Completed by Patient,
Attesting that the Acupuncturist Has Referred Him/Her

(Pursuant to the requirement 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.)

The acupuncturist has referred me to see a physician. It is my responsibility and choice whether to follow his or her advice.

Patient's signature _____________________________________      Date ____________

Acupuncturist's signature ________________________________      Date ____________