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.