INFORMATION AND CONSENT
PLEASE READ THE FOLLOWING CAREFULLY
Dry needling (DN) is a skilled technique performed by a physical therapist using a single-use, single-insertion, sterile filiform needle, which is used to penetrate the skin or underlying tissue to effect change in body conditions, pain, movement, impairment and disability. Like any treatment, there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving your consent for dry needling treatment.
Risks of the procedure
The most serious risk associated with DN is accidental puncture of a lung (pneumothorax). If this were to occus, it may require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe lung puncture, while rare, may require hospitilisation.
Other risks may include bruising, infection or nerve injury. It should be noted that bruising is a common occurrence and should not be a concern. The monofilament needles are very small and do not have a cutting edge; the likelihood of any significant tissue trauma from DN is unlikely.
I have read and fully understand this consent form and attest that no guarantees have been made on the success of this procedure related to my condition. I am aware that multiple treatment sessions may be required, thus this consent will cover this treatment as well as subsequent treatments by this facility. All of my questions, related to the procedure and possible risks, were answered to my satisfaction.
My signature below represents my consent to the performance of dry needling and my consent to any measures necessary to correct complications, which may result. I am aware that I can withdraw my consent at any time.
Physiotherapy treatment is generally an effective and safe form of treatment, however, like any treatment there are benefits and risks. The purpose of this form is to let you know what your rights are and how we address the issue of collaborative decision making and informed consent between physiotherapist and patient.
Physiotherapists in this practice will discuss your condition and options for treatment with you so that you are appropriately informed and can make decisions relating to treatment. You may choose to consent to or refuse any form of treatment for any reason including religious or personal grounds. Once you have given consent, you may withdraw that consent at any time.
PLEASE READ AND SIGN THE FOLLOWING
Questions of a personal nature
Your physiotherapist may ask personal questions relating to your injury and how your injury impacts your 'activities of daily living'. The more information you provide, the more likely it is that the physiotherapist can provide an effective treatment. It is your choice as to what information you choose to provide. If you feel uncomfortable with a particular question or group of questions, please let the physiotherapist know and they will cease.
During the examination, assessment and treatment, it may be necessary for your physiotherapist to make physical contact. Your physiotherapist will ask your permission before making physical contact with you in any way. Wherever possible, contact will be made using a towel or other forms of screening. Physical contact requires your expressed consent. You may withdraw consent at any time, at which point, all physical contact will cease immediately. Please inform your physiotherapist if you feel uncomfortable at any time.
Risks related to treatment
As with all forms of treatment, there are risks and benefits. The physiotherapist will discuss any forseeable risks with you prior to administering treatment. In some cases, the physiotherapist may ask you to read informion related to a particular treatment and they may request that you sign a further consent form. This is to ensure that you fully understand any risks involved. You may withdraw your consent at any given time, even if you have previously signed a consent form.
Children and minors
Consent from a custodial parent is required to treat a minor.
Where a person is incapable of understanding the risks and benefits of treatment, consent may be provided by another person legally authorised to provide such consent. Evidence of legal authorisation is required in such circumstances.
Sharing of information
In the process of ensuring quality treatment provision, information on your condition, treatment, and in some cases, claim status may be given and received with doctors, insurers, solicitors, employers and other treatment providers.
You need to let us know
The risk related to some treatments can increase if the physiotherapist is not aware of certain facts. Please inform the physiotherapist if you have:
I First Name* Last Name* have read and understood the above statements relating to consent for treatment. I offer my consent to receive treatment within the practice. I agree to this consent remaining valid until such time as I withdraw my consent.