Laser Therapy Waiver

Dry Needling Consent to Treat Form

Dry Needling (DN) involves inserting a tiny monofilament needle into symptomatic tissue with the intent to reduce pain, increase circulation and improve function of the neuromusculoskeletal system. DN is not traditional Chinese Acupuncture, but instead is based on neurology, physiology and western medical principles. DN is a valuable treatment for musculoskeletal pain; however, 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 occur, it may likely only 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 can require hospitalization. This is a rare complication and in skilled hands should not be a concern.

Other risks may include bruising, infection and/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.

Location

Are you taking blood thinners?*

YesNo

Are you or is there a chance you could be pregnant?*

YesNo

Are you aware of any problems or concerns with your immune system?*

YesNo

Do you have any known disease or infections that can be transmitted through bodily fluids?*

YesNo

Do you have allergic reactions to metals?*

YesNo

Do you have any tissue or medical device implants anywhere in your body?*

YesNo

Have you had any surgical procedures?*

YesNo

Comments

If you answered yes to any of the above please explain

Patient's Consent:

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. Al 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 I can withdraw my consent at any time.

I {parent} {patientFull} authorize the performance of Dry Needling.

I understand the above and consent to treatmentI understand that failing to complete any part of my treatment program will reduce my chances of success.

Are you 18 years or older?*

YesNo

Parent / Guardian (if under 18 years old)

First NameLast Name

Patient Full Name*

First NameLast Name

Today's Date*

Date

Signature*

Dry Needle Therapy