Acupuncture and Dry Needling Consent Form
Expected treatment benefits:
- Pain reduction
- Decrease muscle and spasm and tension
- Promote general well-being
- Induce local and general relaxation
- Promote general well-being
Possible adverse effects:
Following are the known possible adverse effects associated with electro-acupuncture and dryneedling. Your physiotherapist will discuss this with you and explain if you are at any enhanced risk.
- Bleeding and bruising
- Aggravation of the symptoms
- Mild Pain at the needle site
- Drowsiness
- Pain at site other than needle site
- Nausea
- Fainting
- Bent or stuck needles
- Headache
- Allergy or infection
- Pneumothorax
Although acupuncture and dry needling are established procedures, there may be other adverse effects that have not been recorded. If you experience any of the above or notice anything unusual about your health following your treatment, then you should contact your physiotherapist or your general physician straightaway.
Statement Of Consent
I confirm that I have read, understood and had the opportunity to ask questions related to the information on this form and about the proposed acupuncture and dry needling treatment. I understand that single use disposable needles are used for the treatment. Treatment is likely to involve the intended benefits and possible adverse effects, therefore I voluntarily give consent to receive electro- acupuncture/dry needling treatment from my health care provider stated below. I understand, I can withdraw my consent at any time from the treatment involving acupuncture and dry needling. I agree not to disturb the needles during the treatment and will ask for assistance if I have any concerns.