Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

I authorize Jennifer Stevenson L.Ac. at Jade Spring Acupuncture to have access to the medical records originated by Tiffany Steinmetz L.Ac. at SynerChi Acupuncture for the purpose of transferring my care to Jennifer. *

I agree

Today's Date *

MM

DD

YYYY