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Dry Needling Consent Form
Is there anything your physical therapist needs to know?
*Have you ever fainted or experienced a seizure?
*Do you have a pacemaker or any other electrical implant?
*Are you currently taking anticoagulants (e.g. apsirin, warfarin, Coumadin)?
*Are you currently taking antibiotics for an infection?
*Do you have a damaged heart valve, metal prosthesis, or other risk of infection?
*Are you pregnant or actively trying to get pregnant?
*Do you suffer from metal allergies?
*Are you a diabetic or do you suffer from impaired wound healing?
*Do you have hepatitis B, hepatitis C, HIV, or any other infectious disease?
*Have you eaten in the last two hours?
*Do you agree to perform bloodwork (paid by Viverant) if needle stick occurs to PT within 1 business
Clinic Location
*Your Primary Viverant Location
Statement of Consent

I confirm that I have read and understand the above information, and I consent to having dry needling treatments.

*Patient/Legal Representative First Name
*Patient/Legal Representative Last Name
*Patient/Legal Representative Signature
Therapist Witness Signature

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