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IMFORMED CONSENT TO DRY NEEDLING TREATMENT FOR CLIENTS

CBD Health Plus  - Chiropractic Care

Please read this document carefully but do not sign it until you have been introduced to your treating practitioner.  You will have the opportunity to ask any questions you may have at this time.  This document is designed to inform you of the possible risks and adverse reactions to dry needling treatment (DNT). It is your right to know this information in order for you to give informed consent to your treating practitioner.

What are the possible risks & adverse reactions in relation to DNT?

DNT is a safe treatment option; serious side effects are rare with an incidence of 1 in 10,000 treatments.

The possible risks and adverse reactions to DNT include but are but are not limited to temporary pain, nerve injuries, bleeding (3%), bruising, swelling, infection and nerve shock, nausea, drowsiness, increased symptoms, fainting & Local skin inflammation.  Other more serious but rare events include injury to the heart or lung (cardiac tamponade& pneumothorax), deep venous thrombosis, blood vessel occlusion, brain stem injury, septic arthritis, and abscess.

What are the procedures we have implemented to reduce the above risks?

Full & complete Case History & Examination

We will always take a thorough case history that covers your presenting complaint, past history and medical history.  We will also carry out a thorough examination to determine the nature of your complaint as well as reduce any risk factors.

DNT Training – Our practitioners are qualified to provide patients with DNT & have satisfied the requirements of the training program they undertook in order to provide this treatment

DNT- Safety Protocol

  • If DNT is indicated, prior verbal permission will be obtained
  • All DNT needles are single use only, sterile and of the highest quality possible
  • All practitioners will ensure they meet strict clinic hygiene requirements before applying DNT

Client rights to privacy & Modesty

It is always our intention to respect your right to privacy and to protect your modesty during treatment. AS part of the examination & treatment process you may be required to remove your clothing. This is in order for us to determine the nature of your symptoms and to be able to effectively treat you. We will always endeavour to minimise the amount of clothing you will be asked to remove & cover those areas that are not being treated directly. If you would like to use a gown during your treatment please let your practitioner know.  If you have any concerns about this aspect of your treatment please do not hesitate to talk to your practitioner.

Treatment of Patients under 18 years of age

It is the policy of this clinic that any person under the age of 18 must have their parent or legal guardian present during their child’s initial consultation.  It is strongly recommended that a parent or legal guardian should attend all subsequent appointments.  In the case where a parent/legal guardian is unable to attend a child’s initial consultation, we will ask the parent/legal guardian to read and sign this consent form prior to their child’s appointment.

Patient consent

I hereby request and consent to the performance of treatment on me by my treating practitioner. I do not expect, unless asked, the treating practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise judgement during the course of the treatment, which they feel at the time, based upon the facts then known, is in by best interests.

I intend this consent forms to cover the entire course of treatment for my present condition, and for any other future condition(s) for which I seek treatment. I understand that I can withdraw my consent at any time.

Signing this form does not remove my rights to withdraw from any treatment option my practitioner my offer now or in the future.

PLEASE DO NOT SIGN THIS FORM UNTIL YOU HAVE SEEN YOUR PRACTITITONER.

Dated: April 10, 2020 

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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