MDN Level 1 & 2 Liability/Image Consent Forms for Day 1

MASTER DRY NEEDLING LEVEL LIABILITY WAIVER. PLEASE SCROLL AND READ TILL END OF PAGE. THIS FORM HAS 3 PAGES
Full Name with Credentials*

First NameLast NameCredentials (PT/ATC/DC etc)
Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Course Start Date (Day 1)*

MonthDayYear
Date
Course Location (City & State) *
Name of Instructor*
Which SEMINAR*

Level 1Level 2Pelvic
Comments / Any medical information that you want to tell us. (If none, please type none)*
The following is a list of conditions that are the most common absolute and relative contraindications to Dry Needling therapy:

Spontaneous bleeding or bruising
Irregular heart beat Tendency to bleed (taking anticoagulant therapy)
Compromised immune system
Previous adverse reaction to acupuncture or dry needling therapy
Seizure induced by previous medical procedure
Unstable diabetes
Unstable angina
Congenital or acquired heart valve disease
Recent cardiac surgery or congestive cardiac failure
Recent radiotherapy
Varicose veins
Malignancy
Hematoma
Pregnancy
Eczema or psoriasis
Peripheral neuropathy
Recurrent infections
Epilepsy-stable or unstable
Schizophrenia
Chronic edema or lymphedema
Depression
Chronic fatigue
Acute cardiac arrhythmias
Open skin wounds or injuries
Allergy to Nickel or Chromium
Human Immunodeficiency Virus (HIV)
Hepatitis B or C

Please contact us if you have had cosmetic or surgical implants inserted into your body including but not exclusive to breast, buttock or pectoral implants.

We strongly advise that you consult your medical doctor if you have any of these conditions to confirm that it is safe for you to attend the practical course. If you are in any doubt please do not hesitate to contact us.

The possible risks and adverse reactions to dry needling therapy include but are not limited to temporary pain, bleeding, bruising, infection, dizziness, nerve injury, pneumothorax, pregnancy termination, blood pressure changes, rash, fainting, muscle soreness & fatigue. A published paper referenced below detailed adverse events as follows: Serious Adverse Events (AE's): pneumothorax, cardiac tamponade & damage to organs (0.04% Mild or moderate AEs: bruising (7.55%), bleeding (4.65%), pain during treatment (3.01%) and pain after treatment (2.19% Uncommon AEs: aggravation of symptoms (0.88%), drowsiness (0.26%), headache (0.14%), and nausea (0.13% Rare AEs: fatigue (0.04%), altered emotions (0.04%), shaking, itching, claustrophobia, and numbness (all 0.01% Brady, S et al. Journal of Manual and Manipulative Therapy 2014, Vol. 22, No. 3, 134-140

My signature below affirms the following statements: There is some risk involved in any procedure that involves inserting needles of any kind into the body. It is possible to puncture organs (for example, lungs) or blood vessels. The most serious risk, although it is extremely rare, is pneumothorax secondary to lung puncture. I understand hematomas can develop secondary to needle insertion. The possibility of accidentally inserting a needle into a nerve also exists. I am also aware that vasovagal reactions sometimes occur, resulting in fainting. Infections, though rare, have been reported. I understand that relatively benign and rarely more serious adverse events may occur. I also understand the risk of serious harm is highly unlikely.

My signature below also signifies that I understand that participants practice on one another during the course of the seminar. I am willing to participate in this method of learning and will allow needles to be inserted into my body for educational purposes. By agreeing to this, I also release Total Motion Release Seminars, Master Dry Needling seminars, the participants and the instructor(s) from any liability both during the seminar and in my future practice of the technique.
Liability Signature*

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***Female attendees must sign below to affirm they are not pregnant.

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PROFESSIONAL ACTIVITIES WAIVER

Master Dry Needling seminars makes every effort to help each participant aware PRIOR to each seminar the legal stance and requirements of his or her particular board. However, the ultimate accountability is yours to discover and understand!

I understand the practice of Dry Needling is regulated by state and national board agencies. I understand that IT IS 100% MY RESPONSIBILITY to be absolutely certain it is legal to practice DN in the state or states I practice by communicating directly with my board(s) I release TMR Seminars, Inc., Master Dry Needling and all its instructors and/or employees and associates from this responsibility.

Furthermore, I understand that "acupuncture, acupuncturist, LAC and OMD" are terms that are protected by law and are ONLY to be used by licensed acupuncturists. I understand that when asked what Dry Needling is I'm NOT allowed to use phraseology like "the western, medical form of acupuncture," or "medically-approved acupuncture" or "research-based acupuncture" in an effort to say DN is like acupuncture except it is supported by modern research. understand this pertains to oral, written and all marketing references as well.

Finally, I understand that the billing of Dry Needling to an insurance carrier is a gray area that I must clarify with insurance companies if I decide to bill them.
Professional Activities Waiver Signature*

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Date*

MonthDayYear
Date

IMAGE CONSENT RELEASE FORM

I hereby give Master Dry Needling Seminars (MDNS) and Total Motion Physical Therapy (TMPT) the right and permission to broadcast, display and/or publish and distribute my photograph, image, voice and/or name in promotional or marketing materials which may include, but are not limited to, newspaper, press releases, brochures, online marketing, video, articles, magazines, radio, commercials and catalogs.

I understand that MDNS and TMPT will not be in a position to, and is not committed to, attempt or control any redistribution of such materials by third parties receiving such items

I hereby waive any right to inspect or approve the finished materials that may be used by the above in connections with any of the above purposes.

I hereby release, discharge and agree to hold harmless MDNS and TMPT, including their respective directors, employees, contractors or vendors from and against any liability as a result of distortion, blurring or alteration that may occur in the taking, processing, reproduction, publishing or distribution of the finished materials, and from any and all claims, actions and demands of whatsoever nature, including but not limited to claims of libel, defamation or invasion of privacy, arising out of or in connection with the use of photographs, videos or reproductions.

I hereby warrant that I am competent to contract in my own name insofar as the above is concerned. A parent or guardian must sign the release if the individual photographed is under 18 years of age.

I have read the foregoing release, authorization and agreement before signing below and state that I fully understand the contents thereof.
Image Consent Signature

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