Sample Recommendation form

Please use the template below to adapt to your needs. Feel free to copy and paste into word processing program to edit for your specific needs.


Date:

Re:

Dear Dr. ______________,

The above listed physician has requested privileges in Medical Acupuncture, and has given your name as a reference with regard to his/her qualifications for these privileges. We would appreciate your response to the following questions:

  • Does this physician routinely establish a diagnosis within the framework of Western medical thought?
  • Does this physician routinely perform an appropriate medical work-up of the patient's condition?
  • Does this physician routinely evaluate multiple treatment options and document the rationale for choosing Medical Acupuncture in each particular situation?
  • Has this physician experienced a significant percentage of negative outcomes as a result of the use of Medical Acupuncture?
  • Does this physician always use sterile technique when performing Medical Acupuncture?
  • Does this physician exercise good judgement when commonly recognized medical treatment options for some conditions are available where Medical Acupuncture is also an option?
  • Does this physician have an acceptable record with regard to the appropriate referrals of patients to specialists when warranted?
  • How long have you known the applicant?
  • On what type of interaction with this physician do you base your recommendations?

Comments:

Name (please print):
Signature _________________________ Date_________________

 

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