Dry Needling Consent Form

Your Viverant provider may recommend Dry Needling as part of your therapy. Please review the following question and select yes or no to determine if Dry Needling is appropriate for you:

"*" indicates required fields

Have you ever fainted or experienced a seizure?*
Do you have a pacemaker or any other implant?*
Are you currently taking anticoagulants (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 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?*
Do you agree to perform bloodwork (paid by Viverant) in 1 business day if needle stick occurs to PT?*
Patient Name*
MM slash DD slash YYYY