Sample DN Consent & FAQ Forms

Sample Dry Needling Consent Forms

In the US and other countries, a number of state boards and jurisdictions require a written DN consent form. Here we provide a few samples. The samples have not been reviewed by the legal counsel of Myopain Seminars and may not necessarily meet the requirements of each state or jurisdiction. You are free to review, download, and modify the form that best meets your specific requirements. If necessary, have an attorney review the form you created, or request a consent form from an attorney. If you would like us to add your consent form, let us know!

• The Nevada Board of Physical Therapy Examiners has provided a sample DN consent form.
• Bethesda Physiocare (Jan Dommerholt’s PT clinic) uses its own BPC Dry Needling Informed Consent form for use in the State of Maryland.
• One of our course participants shared their Trigger Point Dry Needling Consent Form.
• A course participant in New Jersey shared this consent form composed by attorneys: New Jersey Consent Form
• From Australia, here is the Cairns -Dry-Needling-Consent-Form.
• Also from Australia, Allied Family Physiotherapy uses the AFP-Acupuncture-Dry needling consent form.
• From New Zealand, Zoe Eves-Cowell Myotherapy & Dry Needling uses the Myotherapy & Dry Needling Consent Form.
• The Washington State Board of Physical Therapy, with help from community partners, has developed an example of an informed consent form that includes all the required information. Physical therapists are not required to use this example form, but they can copy some or all of the form for their own use.

Sample Dry Needling FAQ form

Bethesda Physiocare (Jan Dommerholt’s PT clinic) uses a FAQ Dry Needling form for patients.