Trigger Point Dry Needling
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
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-
Area Code
Phone Number
Date
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is TDN ?
I have read and understand TDN consent and request for procedure.
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YES
NO
Are you pregnant?
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YES
NO
Are you immunocompromised?
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YES
NO
Are you taking blood thinners?
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YES
NO
Presence of implants?
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YES
NO
DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM. You have the right to withdraw consent for this procedure at any time before it is performed. ------------------------I authorize Nina Evangelista, PT, CMTPT, CEEAA, AIB-VR to perform Trigger Point Dry Needling on me after education, consent, precautions, what to expect has been explained to me.
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Physical Therapist Affirmation: I have explained the procedure indicated above and its attendant risks and consequences to the patient who has indicated understanding thereof, and has consented to its performance
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DateTime
p. 443.979.7171
AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170
Columbia, MD 21046
f. 667.200.5908
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