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.



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?


Name (please print):
Signature _________________________ Date_________________


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