Dry Needling Consent Form

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

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:

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 Note: Your signature is required to submit this form.