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Physician’s
Permission
Physician’s Name: __________________________________________________________ Physician’s Address: ________________________________________________________ Physician’s Telephone _______________________________________________________ I have been treating _____________________ since ____________ for the following condition(s): (patient’s name) (date) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ There is no reason to believe that massage or bodywork treatments will harm this patient’s progress. However, please note the following considerations/medications warrant special attention: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Should you notice anything unusual or suspicious in the treatment or progress of this patient, please notify my office immediately. __________________________________________________________________________ Physician’s Signature Date Please return completed form to: Karin Whitney Cooke, RN KoKoLuLu Farm and Qigong Center P.O. Box 340 Hawi 96719 (808) 889-9893 |
