Consent Form

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PATIENTS UNDER THE AGE OF 18

As is deemed best practice and legally required when working with children, it is mandatory that the patient's parent/legal guardian is present during their treatment.

DRY NEEDLING:

This adjunct to physiotherapy has specific uses and contra-indications. If your physiotherapist feels your problem may respond to dry needling, they will discuss this with you. A brief summary of what is involved in now set out :
• Dry needling is an invasive procedure used to treat trigger points in which a solid filament needle is inserted into the skin and muscle directly at a myofascial trigger point. The aim is to elicit a twitching response from the muscle which then relaxes. This assists in reducing pain. There is also a local increase in blood flow to the area and this helps with healing.
• Since dry needling is an invasive technique there are naturally some potential risks. However,
with our extensive anatomical knowledge we take every precaution to minimise these risks.
• The most serious complication that may occur is a pneumothorax (puncture of the lung tissue). This is extremely uncommon and very unlikely when correct techniques are used. This is only a concern when working in the muscles close to the lungs. If this happened, it may only require a chest x-ray and no further treatment. Symptoms of shortness of breath may last for several days or weeks. A more severe lung puncture may require hospitalisation and reinflation of the lung.
• A more common occurrence post treatment is some bleeding that could cause bruising. Some
bruising is a common occurrence and should not be a concern unless you are taking a blood thinner (aspirin, warfarin).
• As it is an invasive technique, there is a minor risk of infection. All needles used in the clinic are
high quality, disposable and sterile.
• Dry needling is within the scope of practice for Chartered Physiotherapists in Ireland that have undergone appropriate post-graduate training, this is the case for all the physiotherapists at lmokilly Physiotherapy and Sports Injury Clinic.

I have read and understood this information

RADIAL PULSED SHOCKWAVE THERAPY

This adjunct to physiotherapy has specific uses and contra-indications. If your physiotherapist feels your problem may respond to shockwave therapy, they will discuss this with you. A brief summary of what is involved in now set out:
• The treatment involves sending shockwaves through your skin, via an applicator head, to
influence the affected tissues.
• Shockwave provides the following benefits : mechanical stimulation; increased local blood flow; increase in cellular activity; transient analgesic effect on afferent nerves; break down of calcific deposits (primarily but not exclusively in tendons).
• You should be aware that there may be some transient side effects to this treatment that should
self resolve in a few days. These are : reddening, swelling, pain, haematoma, petechiae (red spots) and skin lesions after previous cortisone therapy.
I have read and understood this information

CONSENT FOR PHYSIOTHERAPY:

I consent to physiotherapy assessment and treatment, including dry needling and radial pulsed shockwave therapy, as deemed appropriate by myself and my physiotherapist.
The risks and benefits, including any potential side effects and reasonable alternatives, will be explained to me. I understand I have the rights to ask any questions and decline at any stage without prejudicing further care.
I have read and understood this information

GDPR

The new EU regulations require that we gather your consent for the processing of your data, obtained with regards to the provision of physiotherapy services. This data includes such things as personal identifiers (which are processed in order to communicate with you) and medical information (processed in order to provide services).

I consent to have my identifier details processed. These include: name, telephone, email, home address and, in certain circumstances, work address and employee number.

I consent to having my medical information processed for the purposes of receiving a physiotherapy service and on-going treatment.

I consent to the sharing of my medical information with nominated medical practitioners for the purposes of receiving further medical treatment.

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