TRIGGER POINT DRY NEEDLING CONSENT
 

Complete only if dry needling is recommended.

I understand that trigger point dry needling uses sterile, single-use needles as part of physical therapy treatment. My physical therapist has completed the education and training required to perform dry needling in Colorado and is competent to perform this procedure. 

Potential benefits may include decreased pain, improved muscle function, movement, and physical function. Results vary and no specific outcome is guaranteed. 

I understand that dry needling performed by my physical therapist will not include stimulation of distal or auricular acupuncture points.

Potential risks include, but are not limited to, soreness, bruising, bleeding, dizziness, infection, nerve or blood-vessel injury, and, in certain areas, pneumothorax (collapsed lung). Serious complications are uncommon but possible.

I will inform my therapist of any medical conditions, implanted devices, medications, or other factors that may affect the safety of dry needling. 

I understand that alternatives may include other physical therapy treatments, exercise, education, activity modification, or no treatment.

I have had an opportunity to ask questions and understand that I may refuse or discontinue dry needling at any time.
 

☐ I CONSENT to trigger point dry needling.
☐ I DO NOT CONSENT to trigger point dry needling.
☐ I have received a copy of this consent form, either electronically or printed

Patient Name: __________________________ Date: ____________________
Patient Signature: _________________________________ 
Treating Physical Therapist: __________________________________________