Vail Physical Therapy
Intramuscular Manual Therapy / Dry Needling Consent Form
Dry needling is a physical intervention that is used to treat acute and chronic pain, injury, muscle stiffness, spasm, and swelling. It uses a thin, flexible, sterile needle that stimulates points to promote muscle relaxation, tissue healing, swelling reduction and pain relief.
Dry needling by a physical therapist is not “acupuncture” and does not include the stimulation of auricular or distal points. It is based on Western medical concepts of modern physiology, anatomy, neurology and biomechanics. Dry needling is termed “dry” because at no time will a fluid or medication be injected into your body.
Like any treatment procedure, there are risks for complications, and while these are uncommon, they can occur and must be appropriately outlined prior to consenting to use. Risks include: soreness up to two days, bruising, nerve injury, numbness/ tingling, infection, welts, and pneumothorax (lung puncture).
Symptoms of a pneumothorax include sudden onset of chest pain, tightness in chest, rapid heart rate, rapid breathing, cough, excessive fatigue and shortness of breath. A severe lung puncture can require re-inflation of the lung and hospitalization. To avoid piercing lung tissue, short needles and general caution are utilized around the thorax.
Dry needling will be performed in a manner consistent with generally accepted standards of practice, including clean needle techniques, and standards of the CDC to decrease the risk of infection.
If at any time during treatment you feel uncomfortable, nervous, nauseous, or experience pain, the needles will be immediately removed upon your request.
If you currently have an infection, bleeding disorder, cancer, hepatitis, HIV/AIDS, a pacemaker, are taking blood thinners and/or immunosuppressant medications, have a metal sensitivity, have recently undergone joint replacement surgery, or are pregnant, then please inform your physical therapist prior to beginning treatment.
Jennifer Martin, DPT has completed the required training hours for Intramuscular Manual Therapy/Dry Needling and has been performing TDN since 2015.
Dave Cimino, DPT has completed the required training hours for Intramuscular Manual Therapy/Dry Needling Level 1 and 2, and has been performing TDN since 2016.
By submitting this form and typing my name below, I acknowledge that I have reviewed this information and understand the risks involved with Intramuscular Manual Therapy / Dry Needling. I have had the opportunity to ask questions and express any concerns, which have been answered to my satisfaction, and I consent to treatment.
I certify that I am either the patient or the patient’s parent/legal guardian and have the authority to provide this consent. I understand that my typed name below constitutes my electronic signature.