Dry Needling Consent Form

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Dry needling is a treatment where fine needles are inserted into specific parts of the body in order to reduce pain or muscle spasm. The procedure is generally very safe and serious side effects are very rare at less than 1 per 10,000.

You need to be aware of the following:

Drowsiness may after treatment in a small number of patients. If so, you are advised not to drive
Minor bleeding or bruising occurs after therapy in about 3% of treatments
Mild pain during treatment occurs in about 1% of treatments. A strong ache during treatment is normal, and a good sign that treatment will be effective
Rarely, fainting can occasionally occur in certain patients, particularly at the first treatment
Single-use, disposable needles are always used<./li>

In addition, if there are particular risks that apply in your case, your practitioner will discuss this with you.

Please answer the following important questions:

Are You Diabetic?

Yes No

Do you currently have an acute infection?

Yes No

Have you ever experienced a fit, faint or funny turn?

Yes No

Do you have lymphoedema?

Yes No

Have you a pacemaker or other electrical implant fitted?

Yes No

Do you have a bleeding disorder?

Yes No

Are you taking anticoagulants?

Yes No

Are you pregnant or actively trying to become pregnant?

Yes No

The purpose, benefits and potential risks of dry needling treatment have been explained to me. I confirm that I have read and understood the above information and I consent to having dry needling treatment. This consent applies for all future dry needling treatments I may be given. However, I understand that I can refuse treatment at any time.

Please sign below to confirm you have read and agree to the information above: