Functional Dry Needling/IMS Consent Form - Nose Creek Sport Physiotherapy, Calgary

Dry Needling Consent Form:

Functional Dry Needling/IMS involves placing a small filament needle into the muscle at the trigger point. A trigger point is typically an area where the muscle is tight and tender. The purpose of the needling is to cause a local twitch response to normalize muscle tone. This, in turn, can help increase the mobility around a joint and decrease pain. This type of needling is often effective in the treatment of myofascial pain. Functional Dry Needling is performed at Nose Creek Sport Physical Therapy by a licensed physiotherapist who has received the required training needed to perform this technique.

It should be noted that Functional Dry Needling is not acupuncture, although both forms of needling use the same type of needle. Patients interested in acupuncture should consult a licensed acupuncturist.
This form is a consent form and general release of liability for this procedure. By signing this form, you are agreeing not to hold Nose Creek Sport Physical Therapy and its staff responsible for any complications that could arise from the usage of this technique. Like all treatments, there are certain risks and potential complications. While complications are rare they can occur and must be considered before giving consent to needling treatment.

Potential Risks and Complications of Functional Dry Needling:
Potential risks that are relatively common are bruising and short-term increased pain. Bruising is not an issue as long as you are not taking a high dose blood thinner. Increased point tenderness pain is common but often goes away within a few hours, leaving the patient feeling looser later that same day or the following day. Some people do not experience any soreness after needling, while for others the soreness can last for more than a few hours. We cannot predict what way you will respond on your first time getting needled. Complications from Functional Dry Needling are not common but can include: hematoma, nerve injury, infection, and accidental puncture of the lung.

Contraindications for needling include: pregnancy, malignant tumors, bleeding disorders, patients on blood thinners, unstable blood pressure, and internal organ disease.

If you marked YES to any of the above, please discuss with your physiotherapist prior to receiving this treatment.

Consent and Release of Liability: I consent to and voluntarily assume the risks of my participation in getting Functional Dry Needling. I will inform Nose Creek Sport Physical Therapy and my physiotherapist of any concerns I have regarding this procedure. I understand that no guarantee or assurance has been made as to the results of this technique and that it may not cure my injury or pain. I confirm that I am not experiencing any of the contraindications listed above. I release, discharge and will not sue Nose Creek Sport Physical Therapy or any of their employees, administrators, owners, etc. from any losses and costs or claims of damage whatsoever caused by or as a result of my participation in Functional Dry Needling. I have read, understand and agree to the terms of this consent form. I am signing this form freely and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

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