Loading...

Please read this fully. If there is any part that is unclear, please ask for assistnace. DO NOT SIGN if there is any part that is unclear. By signing you signify that you understand fully. 

Dry Needling Informed Consent 

 

Please review the following information PRIOR to consenting to the application of dry needling techniques as part of your plan of care.

 

  • Dry Needling is not acupuncture; however, it is a technique that utilizes thin, solid monofilament needles. This needling technique is used specifically to treat myofascial trigger points, muscle spasms, or dysfunctional tissue. Like any medical procedure, there are possible complications. While these complications are uncommon, they do sometimes occur and must be considered prior to giving consent to the procedure. 

 

  • Pain. When a needle is inserted in the correct location, it may briefly reproduce a muscular ache or a twitching response which indicates the technique should be effective in reducing the symptom. You may experience a muscular ache for one or two days followed by an expected improvement in your overall symptoms. It is extremely important that your medical professional is made aware if you are feeling uncomfortable with the treatment. 

 

  • Infection. Any form of skin penetration creates an opportunity for bacteria to enter the system. In order to minimize the risk, your medical professional will follow the proper disinfection procedures and will use only the sterile disposable single-use needles. 

 

  • Bruising or Bleeding. On occasion you may experience a small painless bruise or blood spotting in the treated region. Bruising and the blood spotting of this nature would clear very quickly. 

 

  • Drowsiness. fatigue and autonomic responses.On occasion you may experience a feeling of tiredness, nausea, dizziness, sweating; if this occurs, you will be asked to avoid driving until the feeling has passes; Change in blood pressure, heart rate, flushing of the face or breathing rate are involuntary reflexes which may change temporarily as a result of dry needling; these occur rarely and should give no cause for concern. 

 

  • Pneumothorax.There have been approximately 100 reported cases worldwide of acupuncture needles puncturing a lung. This only occurs when needles are inserted too deeply or incorrectly. Pneumothorax is a serious medical condition requiring admission to hospital. Your medical professional has been trained to avoid the lungs and limit needle depth to avoid this occurring. 

 

Avoid use if you have any of the following conditions: 

  •  HIV or AIDS or Hepatitis 
  •  Unstable Blood Pressure 
  •  Current or Recent Infection 
  •  Pacemaker 
  •  Current use of Blood Thinning Medication 
  •  Cancer 
  •  Current use of Immunosuppressant medication 
  •  Diabetes 
  •  Fear of needles 
  •  Currently Pregnant 

 

I have read this form and I understand the risks involved with dry needling therapy. I have had the opportunity to ask questions and express any concerns, of which have been answered to my satisfaction. I also agree to advise my medical professional of any and all changes in my physical condition whether or not I believe these changes will affect my treatment or plan of care.

 

I consent to dry needling provided by The Cryotherapy Place

 

 

 

         June 1, 2025

 

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!