I understand that I am seeking dry needling treatment for my condition. I understand that dry needling involves the insertion of thin needles into specific points on my body and that there are potential risks associated with this procedure, including bruising, soreness, bleeding, infection, and nerve damage. However, I also understand that dry needling may provide benefits such as reducing pain, improving range of motion, and improving overall function.
The practitioner has met requirements for Level II competency in Dry Needling and is a certified Dry Needling Practitioner. All training was in accordance with the requirements dictated by the Colorado Department of Regulatory Agencies.
This authorization is given with the knowledge and understanding that there are some risks associated with this treatment. These risks may include infection and neurovascular injury. A significant but rare risk is the puncture of a lung (pneumothorax) and symptoms include shortness of breath and chest pain which may last for several days to weeks.
I understand that no guarantee or assurance has been made as to the results of the procedure and it may not cure the condition.
I have been informed of the details of the dry needling procedure, including the areas of my body that will be treated, the number of needles that will be used, and the length of each treatment session. I have also been informed of other options for addressing my condition and the estimated number of dry needling sessions required.
I have read and fully understand this consent form. I understand that I should not sign this form if all items, including my questions, have not been explained or answered to my satisfaction, or if I do not understand any of the items or words contained in this consent form. I understand that I can withdraw this consent to the procedure at any time before the beginning of the procedure.
I (patient or guardian), hereby authorize Jaime Odin PT, DPT to perform Dry Needling.