Patient Information and Consent for Dry Needling

DeBruin Physical Therapy, LLC

Patient Information and Consent for Dry Needling as a Procedure
for the Assessment and Treatment of Myofascial Trigger Points and Tender Points

Myofascial trigger points and tender points which appear in soft tissue, and are painful sites, reflect abnormal nervous system activity associated with many neuro-musculo-skeletal conditions that are treated in our office. The procedure known as Dry Needling is an important tool for diagnosing, treating and monitoring changes in myofascial trigger/tender points. During this procedure, a sterile, very thin, solid filament needle is inserted into tissue that may be associated with one or a number of your complaints. One or a number of needles may be used, and the procedure may be performed during more than one office visit. The number of needles and the frequency of the procedure will depend entirely on your condition at each office visit. There is little to no pain with this procedure. There is little to no bleeding with this procedure. While an infection is an unlikely event with this procedure, whenever there is penetration of the skin, there is the risk of infection. Other unlikely but possible events include fainting, soreness, or pneumothorax (lung puncture). If you have a fear of needles, a genetic bleeding disorder, a history of a blood disorder that can be transmitted to another person, are regularly taking any blood thinning medication (for example, Coumadin or Warfarin), or are regularly taking any pain relievers containing ibuprofen, NSAIDS, aspirin or acetaminophen (for example, Tylenol, Advil, Aleve, or Bufferin), please inform us by placing a check mark as indicated below:

Check all that apply*
- I have a fear of needles.
- I have a genetic bleeding disorder. Please specify in the comments section below.
- I have a history of a blood disorder that can be transmitted to another person. Please specify in the comments section below.
- I am regularly taking blood thinning (anti-coagulation) medication. Please specify in the comments section below.
- I am regularly taking pain relievers. Please specify in the comments section below.
- NONE
Comments:
Patient Consent
I have read this Patient Information and Consent carefully, I understand this procedure is not acupuncture and I have had an opportunity to ask questions and obtain any desired clarification, and I consent to having the procedure of Dry Needling performed on me. I give permission to have the treated region(s) photographed for records/educational purposes.
Patient Name*
First Last
Patient Email*
Date*
MM slash DD slash YYYY
Initials*
Parent/Legal Guardian Name
First Last
If patient is less than 18 years of age parent or legal guardian must initial below.
Parent/Guardian Initials

Patient Information and Consent for Dry Needling

DeBruin Physical Therapy, LLC

Patient Consent