Dry Needling New Patient Intake

New Patient Dry Needling Intake

Medical History

Please indicate any conditions that you have had or currently have:

Policies and Procedure for Massage Therapy

Please understand if you are late for your appointment you will receive the time remaining for your massage. The appointment time was reserved for you and you will be expected to pay for full time reserved.  Please arrive at least 10 minutes prior to your appointment to allow check in and visit restroom if heeded. This will allow you to receive the full time of your massage. The appointments are scheduled back to back therefore I cannot run over into someone else's massage time.

Reserve appointment: A credit card Is required to reserve an appointment. This will guarantee your massage time.

Cancellation policy: A 24-hour notice is required when cancelling an appointment. In the event you do not give a 24-hour notice, your credit card will be charged for the massage. We will give you a courtesy call to inform you of the charge. A receipt can be mailed to you.

Payment: Payments are due at the time services are rendered, Any payment not made at the time services are rendered will incur a $25.00 charge. In the event there is a problem with the credit card charged, there may be additional charges.

Returned checks; Any returned check will incur an additional $25.00 fee.

HIPAA Privacy Policy: Please see attached privacy policy. By signing you are acknowledging you understand the privacy policy.

Termination of Session: The therapist/client has the right to terminate a session at any time for any reason. Please understand that payment may still be due.

If you have any questions or need clarification, please ask.

I have read of had read to me the above explanation of massage treatment. Any questions I have had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely.

To attest to my consent to these procedures, I hereby affix my signature on this authorization for treatment.


What is Dry Needling?

Dry needling is a form of therapy in which fine needles are inserted into myofascial trigger points (painful knots in muscles), tendons, ligaments, or near nerves in order to stimulate a healing response in painful musculoskeletal conditions. Dry needling is not acupuncture or Oriental Medicine; that is, it does not have the purpose of altering the flow of energy ("Qi") along traditional Chinese meridians for the treatment of diseases. In fact, dry needling is a modern, science-based intervention for the treatment of pain and dysfunction in musculoskeletal conditions such as neck pain, shoulder impingement, tennis elbow, carpal tunnel syndrome, headaches, knee pain, shin splints, plantar fasciitis, or low-back pain.

Is Dry Needling Safe?

Drowsiness, tiredness, or dizziness occurs after treatment in a small number of patients (1-3%) and if affected, you are advised not to drive. Minor bleeding or bruising occurs after dry needling in 15-20% of treatments and is considered normal. Temporary pain during dry needling occurs in 60-70% of treatments. Existing symptoms can get worse after treatment (less than 3% of patients); however, this is not necessarily a "bad" sign. Fainting can occur in certain patients (0.3%), particularly at the first treatment session when needling the head or neck regions, Dry needling is very safe; however, serious side effects can occur in less than 1 per 10,000 (less than 0.01%) treatments. The most common serious side effect from dry needling is pneumothorax (lung collapse due to air inside the chest wall). The symptoms of dry needling-induced pneumothorax commonly do not occur until after the treatment session, sometimes taking several hours to develop. The signs and symptoms of a pneumothorax may include shortness of breath on exertion, increased breathing rate, chest pain, a dry cough, bluish discoloration of the skin, or excessive sweating. If such signs and/or symptoms occur, you should immediately contact your physical therapist or physician. Nerves or blood vessels may be damaged from dry needling which can result in pain, numbness or tingling; however, this is a very rare event and is usually temporary. Infection (1 per 66,000) or damaged to internal organs (1 per 200,000) has been reported in the medical literature following needling, however these are extremely rare events.

Have you ever fainted or experienced a seizure?
Do you have a pacemaker or any other electrical implant?
Are you taking anticoagulants (blood-thinners e.g. aspirin, 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 for a pregnancy?
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?
Only single-use, disposable needles are used in this clinic.


The purpose, benefits and potential risks of dry needling have been explained to me.

I confirm that I have read and understand and above information, and I consent to having dry needling treatments. I understand that I can refuse treatment at any time.



Your insurance does not pay for all your healthcare costs. Some items and services are not considered "covered benefits" under your health insurance plan and as such, your insurance will not pay for these services. 

Your physician believes that the following service(s), although not covered by your health insurance, are an important part of your chiropractic care and recommends that you receive these services as part of your current treatment plan. However, since the services listed here are not considered to be a covered benefit under your health insurance, should you choose to receive these services; you will be personally responsible for the payment of such services. The purpose of this notice is to help you make an informed choice about whether or not you want to receive these items or services. 

The services recommended by your physician are listed below:

  • DRY NEEDLING CPT CODE 20560/20561:  $55-$100

The total cost for the services/items recommended by your physician are:

$55-$100 PER VISIT

I acknowledge that I have been informed in advance of receiving these services, that these services are not covered by my health insurance plan. I have chosen to receive these services and understand that I will be financially responsible for the charges indicated above.

This form must be signed by the patient or legal guardian PRIOR  to receiving any non-covered services or items and must be maintained in the patient's medical record.

Thank you for taking the time to fill out this form.

Contact Us to Schedule an Appointment

We look forward to hearing from you!

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