I voluntarily consent to physical therapy treatment and services deemed necessary by my physical therapist and/or physician. I am aware that the practice of physical therapy is not an exact science and I acknowledge that no guarantees have been made to me as to the results of these services at PHYSICAL THERAPY SPECIALIST, PC with Mark Hernandez, PT. It is the therapist’s and facility’s sincere intent to educate me on the processes of treatment and eventually discharge from our services. Therefore, if “hands-on” manual therapy techniques and/or exercise techniques that are being used to retrain, recruit, and restore normal musculoskeletal function are not understood or desired, it is my responsibility to obtain a clearer understanding of the therapists objectives and outcomes, and how he/she is trying to achieve them or refuse this aspect of treatment. If I do not consent or feel uncomfortable physically or emotionally with any aspect of the treatment, it is also my responsibility to make this immediately clear to the therapist providing the treatment.

This consent shall be on-going for the treatment period.

I have read this form and fully understand and accept its terms and conditions:

I voluntarily consent to DRY NEEDLING treatment as deemed helpful to treating my condition by my physical therapist and/or physician. I am aware that the practice of physical therapy is not an exact science and I acknowledge that no guarantees have been made to me as to the results of these services at PHYSICAL THERAPY SPECIALIST, PC with Mark Hernandez, PT.

I understand DRY NEEDLING is a medical modality with certain risks. Positive reactions include relaxation, feeling energized, and tiredness. Negative reactions include pain where needle is inserted, mild bleeding where needle is inserted, bruising, syncope, nausea, sweating, mild bleeding, disorientation, localized or diffuse aching, localized itching and burning, tingling. If performed in the trunk or rib cage areas, rare risks include visceral injury, pneumothorax, bleeding, and infection. Therefore, if DRY NEEDLING techniques that are being used to retrain, recruit, and restore normal musculoskeletal function are not understood or desired, it is my responsibility to obtain a clearer understanding of the therapist's objectives and outcomes, and how he/she is trying to achieve them or refuse this aspect of treatment. If I do not consent or feel uncomfortable physically or emotionally with any aspect of the treatment, it is also my responsibility to make this immediately clear to the therapist providing the treatment.  Techniques performed will and do conform to standards set and instructed by the American Dry Needling Institute. If any adverse reactions occur, I will contact my physical therapist and seek immediate medical attention if necessary. 

This consent shall be on-going for the treatment period.

I have read this form and fully understand and accept its terms and conditions.

This Agreement constitutes an unconditional release of liability. Please read it carefully. The undersigned hereby releases, discharges, and covenants not to sue Physical Therapy Specialist, P.C., its administrators, directors, officers, agents, members, volunteers and employees, and applicable owners and lessors of the premises upon which physical therapy treatment takes place from all liability, claims, demands, losses or damages on my account caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations; and I further agree that if, despite this release and waiver of liability, assumption of risk, and indemnity agreement, I or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, and HOLD HARMLESS each of the Releasees from any litigation expenses, attorney fees, loss, liability, damage, or cost which any Releasee may incur as a result of such claim. I have read this agreement, fully understand its terms, understand that I have given up substantial rights by signing it and have signed it freely without any inducement or assurance of any nature and intend this document to be a complete and unconditional release of all liability to the greatest extent allowed by law, and agree that if any portion of the agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.