Consent for Dry Needling treatment

I (Full name), in my capacity as: the patient/client (if aged 18 or over),
or
the parent or legal guardian of the patient/client: (Patient/client full name)
who is my: Spouse/Child/Grandchild/Parent/Sibling/Foster Child/Ward
(Please circle the appropriate term)
I do hereby give my consent for the performance of dry needling therapy by my Myotherapist.
I understand that the therapist is appropriately trained to perform the required therapy.
The areas of the body that I consent to have dry needled are:




I am satisfied that the technique has been fully explained to me, and that my concerns have been addressed and that my questions have been answered to my satisfaction. I have read the attached information sheet called “Dry Needling information disclosure”, and am in a satisfactory position to weigh up the risks and limitations of the technique in regard to known and explained side effects.
I understand that the technique is performed within a rehabilitative framework and that I must follow instruction as given by the myotherapist.
I understand that in the event of any litigation arising consequent to this therapy, it can only be done
within the jurisdiction of the Magistrate’s court. The applicant will be responsible for his/her own and the defendant’s legal costs.
I hereby indemnify the therapist and the practice against any liability arising from unforeseen or unknown consequences.