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Dry Needling / Cupping Consent Form

Dry Needling (DN)

DN  is a technique that involves the insertion of acupuncture needling in the soft tissues of the muscoloskeletal system as a means to promote healing within the body. Treatment techniques are based on concepts of motion medicine and should not be considered acupuncture. Risk of injury is real and potential complications could result from DN if proper precautions are not observed. Pneumothorax could result from insertion of a needle into lung tissue; if DN is practiced properly, threat of pneumothorax is extremely low. 



Cupping is a technique that utilizes negative pressure to stretch superficial structures in the human body including skin, fascia, and muscle tissue. The purpose of this technique is to increase microcirculation of the aforementioned soft tissue structures to enhance the healing process. On the human body cupping will cause bruising and temporary marks on the skin. More severe complications could result in blistering of the skin. 

Contraindications to DN and Cupping:

  • Vascular Disease
  • Bleeding or Clotting Disorder
  • Taking Blood Thinners
  • Diabetics with significant sensory and/or circulation disorders
  • Pregnancy
  • Skin Cancer (over affected area)
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I have read the above, i understand the risks involved with dry needling and cupping. I have had the opportunity to ask any questions I had and allmy questions have been answered. I consent to treatment at Revolve Physical Therapy.