Acupuncture Dry needling consent form

Acupuncture / Dry Needling:
What and Why?
  • Acupuncture and dry needling are forms of treatment where very fine acupuncture needles are inserted into the tissues (pierces the skin) in order to create neurophysiological reactions in the body and stimulate a healing effect.
  • Depending on the specific points chosen & technique used, this assists with pain relief, reducing inflammation, improving local immune / healing responses and relaxing muscle spasm to assist healing.
Precautions and contraindications:
Your practitioner will screen for reasons why extra care needs to be taken or whether you should not have acupuncture or dry needling (precautions or contraindications).

    Please indicate whether you have any of the following:

  • especially if history of miscarriage
    (tick yes if you may be or are trying to fall pregnant)
  • (e.g. haemophilia) If yes - what type
  • YesNo


  • (e.g. pacemaker, heart valves, joint replacements, cosmetic surgery)
  • If yes, where:
  • YesNo
    If yes, where:
  • YesNo
  • Heart failure / arrhythmias / Other:

  • (e.g. lupus, rheumatoid arthritis)
    If yes, disease type:

  • If yes - last seizure:

  • If yes, where:

  • YesNo
  • Risks / Side effects:

    Most risks are minor. These may include, but are not limited to:

    • Bruising or bleeding
    • Fainting
    • Nausea
    • Discomfort or rarely pain
    • Alteration of energy levels. Some people may experience either high levels of energy or may feel fatigues after acupuncture / dry needling Very rare (less than 1 in 10, 000)
    • Infections
    • Metal allergy
    • Certain areas have risk of pneumothorax (collapsed lung) (less than 1 in 70,000 - 1.27 million)
  • Cautions after treatment:

    • Fatigue and drowsiness: ensure that before driving a vehicle you are not feeling drowsy or fatigued. If you do experience this - have a snack or drink and rest until you are safe to drive. If you suffer from fatigue or drowsiness after acupuncture ensure you inform your practitioner prior to treatment and arrange for someone else to drive you to and from the appointment.
    • Discomfort and minor bruising: it is normal for some people to experience mild discomfort - particularly in the first treatment or two. Some dry needling techniques typically result in soreness for a day or two. Minor bruising or bleeding may also happen. An ice pack can assist recovery (10-15 minutes - use safely: towel around icepack, remove if too cold or painful).
    • Pneumothorax (punctured / collapsed lung): this is extremely unlikely with appropriate needle application - however if you do experience increasing shortness of breath following acupuncture / dry needling over the shoulders or trunk, please contact your therapist directly or attend to the nearest hospital emergency department.
  • If you have any concerns, please contact your treating practitioner.

    I,(full name) consent to having acupuncture / dry needling techniques as part of my physiotherapy management. I have had the procedure explained to me including potential benefits and risks or side effects as detailed above. I have been given sufficient opportunity to ask any questions.