Dry Needling Consent

Please fill out the following form prior to receiving Dry Needling Treatments.

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, and impairment. 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.

Full Name

Date of Birth

Email Address

Mobile

Reason for Visit

Are you taking any blood thinners? Could you be pregnant? Do you have any issues with your immune system? Do you have any known disease or infection that could be transmitted through bodily fluids? Do you have any implants?

Yes

Have you had Dry Needling or Acupuncture previously?

Yes

If you answered yes to any question, please elaborate

I have read and understood the following: The most serious risk associated with Dry Needling (DN) is accidental puncture of a lung (pneumothorax). If this were to occur, 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 hospitalisation. 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 treatment 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 Barefoot Bodywork. I am over 18 years of age or the parent/guardian of the person stated above.

Thanks for submitting, we'll see you at your appointment!

Barefoot Bodywork
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Dry Needling Consent

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