AVALON HYPNOSIS CENTER
300 N. Ronald Reagan Blvd. Suite 301
Longwood, Fl. 32750
Clinical Referral Foam
Your patient _______________________________________________wishes to undergo hypnotic conditioning and suggestions for the following purpose:
Since we require a physician’s referral in such cases we would appreciate your signature below indicating your approval. Please be assured that I shall keep you informed as to your patient’s progress.
Thank you for your kind attention.
Katheryn Napier, Owner, Senior Hypnotist
For the Physician #___________________
I have examined_____________________________________________ and see no contradiction to the use of hypnosis and hypnotic suggestions in this case.
I have these additional comments and instructions for you: _____________________________________________________
Physician name, address and phone number: Please print or type ____________________________________________________