Thank you for enrolling in Physical Therapy at SHIFT! 

We ask that you complete the following Intake Form (5-10 minutes). 

You may save your progress securely at any time and resume later. 

If you have any questions or concerns, please email physicaltherapy@shiftlife.com or call us at 312-584-0391.

 

Thank you kindly,

The SHIFT Team

I, the Patient, or his or her representative, recognize the need for medical care, and authorize Shift Medical, Ltd., its health care employees, allied health personnel and physicians to render medical care and other services and supplies under the general and specific instruction of the physician. I understand and am aware that the practice of medicine is not an exact science and acknowledge that no guarantee has been made to me as to the result of treatment or examination.

Trigger Point Dry Needling (TDN) involves placing a small filament needle into the muscle at the trigger point which is typically in an area where the muscle is tight and tender. The intent of TDN is to elicit a local twitch response to normalize muscle tone, therefore improving the mobility of the muscle and decreasing the symptoms. Dry Needling is performed at SHIFT by a licensed physical therapist who has received additional training in this technique. TDN is an often effective treatment for myofascial pain. Myofascial pain can be a component of many conditions including joint problems and soft tissue pathologies.

TDN as used in physical therapy is not acupuncture and should not be confused with a complete acupuncture treatment performed by a licensed acupuncturist. A complete acupuncture treatment might yield a holistic benefit not available through a focused dry needling treatment. Patients interested in acupuncture should consult with a state licensed acupuncturist.

This form is a consent form and general release of liability for this procedure. By signing this form, you are agreeing not to hold SHIFT and its staff liable for any complications that may arise from the practice of this procedure. TDN is a valuable addition to standard therapy for musculoskeletal pain. Like any treatment, there are risks and possible complications. While complications are rare, they are real and must be considered prior to giving consent for treatment.

POTENTIAL RISKS AND COMPLICATIONS OF PROCEDURE:
Like any treatment, there are possible complications. Complications related to TDN are infrequent and do not usually require additional medical treatment. The main risks and complications associated with TDN include: bruising, hematoma, nerve injury, infection, and increased pain. Bruising is a common occurrence and should not be a concern unless you are taking a blood thinner. As the needles are very small and do not have a cutting edge, any significant tissue trauma from TDN is unlikely.

The most serious risk associated with TDN is accidental puncture of a lung (pneumothorax). If this were to occur, it may only require a chest x-ray and no further treatment as it can resolve on its own. The symptoms of pain and shortness of breath may last for several days to weeks. A more severe lung puncture can require hospitalization and re-inflation of the lung. This is a rare complication, however, if you feel any related symptoms, immediately contact your TDN provider, your physician, or go to an emergency room. If a pneumothorax is suspected you should seek immediate medical attention from your physician or if necessary go to the emergency room.

Contraindications for the use of TDN include: pregnancy, malignant tumors, medical emergencies or in the place of surgical intervention, unstable blood pressure, and internal organ diseases.
Relative contraindications: patients on blood thinners and bleeding disorders. and physicians to render medical care and other services and supplies under the general and specific instruction of the physician. I understand and am aware that the practice of medicine is not an exact science and acknowledge that no guarantee has been made to me as to the result of treatment or examination. 

If you marked YES to any of the above questions, please discuss with your physical therapist prior to receiving TDN.

 
CONSENT AND RELEASE OF LIABILITY:
I consent to and expressly and voluntarily assume the risks of my participation in this procedure. I will inform my Physical Therapist of any questions or concerns I have concerning my treatment. I understand that no guarantee or assurance has been made as to the results of this procedure and that it may not cure my condition. I certify that I am not experiencing the contraindications listed above. I hereby release, discharge and covenant not to sue, SHIFT Medical, Ltd., SHIFT Sciences, LLC, their respective affiliates, subsidiaries, officers, directors, owners, agents, employees, heirs, executors, administrators, successors, and assigns from and against any and all liability, suits, losses, costs, expenses or other claim of damage whatsoever, caused by or as a result of my participation in this treatment method. I have read, understand and agree to the terms of this consent. I have been given an opportunity to ask questions and all questions have been answered to my satisfaction. I acknowledge that I am signing the agreement freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.