Myofascial Dry Needling and Cupping Consent form (feel free to edit)
Acupuncture/Dry Needling Consent Form
Dry needling is a valuable adjunct treatment for chronic pain, stiffness, and to deactivate myofascial trigger points. 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.
With the dry needling technique, a fine, flexible and sterile needle is used. The purpose of the needling is to release shortened bands of muscle caused by abnormal functioning of the nervous system. No drugs are injected.
Dry needling may cause an increase in pain for one to three days followed by an expected improvement in the overall pain state. The increased pain is related to overactive shortened muscle bands that have not been released and to the soreness caused by the “twitching” of the muscles.
Any time a needle is used there is a risk of infection. However, we are using new, disposable and sterile needles, and infections are extremely rare. A needle may be placed inadvertently in an artery or vein. If an artery or vein is punctured with the needle, a hematoma (or bruise) will develop. If a nerve is touched, it may cause paresthesia (a prickling sensation) which is usually brief, but it may continue for a couple of days. When a needle is placed close to the chest wall, there is a rare possibility of a pneumothorax (air in the chest cavity).
Fortunately, all these complications are not fatal and are readily reversible. A gown is provided for female patients. However, for a proper and thorough examination and treatment, the gown may be opened up from the back or it may be partially moved by the practitioner. Care will always be taken to respect your privacy.
An ancillary technique that we also use is cupping where suction cups are applied to the skin with the therapeutic aim of increasing nutrient-rich blood supply to the injured area, to decrease congestion as well as to improve general range of motion. Myofascial cupping and dry needling are generally safe for most people however patients are requested to inform practitioners about conditions such as pregnancy, pacemakers, a history of vascular diseases such as DVT or varicose veins, open wounds, and the use of blood thinners or immunosuppressant medications prior to the treatment.
A temporary side effect of cupping is discolouration of the area cupped. These marks are temporary and will fade within a few days.
I have read or had read to me the above; I understand the risks involved with dry needling and/or cupping. I have had the opportunity to ask any questions I had and all of my questions have been answered. I consent to examination and treatment at ( insert clinic name here )including Acupuncture, Dry needling and/or Cupping
Signature: _____________________________ Date: ______________
Print name: _____________________________