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Kinematics with Kelly

Dry Needling Consent Form

Dry Needling (DN) involves inserting a thin/flexible monofilament needle into symptomatic tissue to reduce pain and improve function. Benefits from DN can be experienced immediately or over a few days to weeks. DN is not Traditional Chinese Acupuncture. DN is based on anatomy, neurology, and physiology. DN has some risks that can occur with the treatment. In the hands of a skilled professional, these risks are small, but you should still be aware of the potential adverse events. The most likely adverse events are listed below by their level of severity (“Serious”, “Significant”, and “Mild”) and how often it may occur (“Common” <10%, “Uncommon” <1%, and “Rare” < 0.1%).

Kinematics with Kelly

There are other conditions that require consideration so please answer the following questions:

Are you taking blood thinners?
Yes
No
Are you pregnant?
Yes
No
Are you receiving any treatments or have a medical condition effecting your immune system?
Yes
No
Do you have any known disease or infection that can be transmitted through bodily fluids?
Yes
No
Have you experienced an allergic skin reaction to metals like chromium or nickel?
Yes
No
Do you have any medical devices or implants anywhere in your body?
Yes
No
Have you had any surgical procedures?
Yes
No

Patient’s Consent:

I have read and fully understand this consent form and attest that no guarantees have been made on the success of this procedure related to my condition. I am aware that multiple treatment sessions may be required, thus this consent will cover this treatment as well as subsequent treatments by this facility. All of my questions, related to the procedure and possible risks, were answered to my satisfaction. My signature below represents my consent to receive dry needling and my consent to any measures necessary to correct complications, which may result. I am aware I can withdraw my consent at any time.


I,

read and understand the risks, all of my questions have been answered, and I am willing to be treated with dry needling.

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