Clinic template
A Cliniko dry needling consent form template for physiotherapy clinics
This form adds a contraindication and precaution screen (bleeding disorders or anticoagulants, pregnancy, epilepsy, diabetes, skin conditions, implanted devices, immune compromise, capacity to consent) and dry needling specific risks to the clinic's general treatment consent. It is built as a separate Cliniko patient form so a patient's file shows exactly when dry needling was specifically discussed and agreed to.
Last checked 25 Sep 2026 against the sources listed at the end of this page.
Free template ยท Cliniko
Patient form: procedure specific consent: physiotherapy
The template: 18 fields
| Section | Field | Type | Notes |
|---|---|---|---|
| What dry needling is | Explanation of the technique | Text | Cliniko type: Paragraph text (shown as description). Plain language explanation that dry needling involves inserting a thin filament needle through the skin into muscle, distinct from acupuncture, and state that this form is in addition to the clinic's general treatment consent, not instead of it. |
| Contraindication and precaution screen | Bleeding disorder or taking anticoagulant or antiplatelet medication | Radio | Cliniko type: Multiple choice. Options: No / Yes. A yes answer prompts the practitioner to discuss and record a decision below rather than automatically stopping the form, since Cliniko cannot branch on the answer. |
| Contraindication and precaution screen | Pregnant or possibly pregnant | Radio | Options: No / Yes / Not applicable. |
| Contraindication and precaution screen | Local skin infection, open wound or skin condition at the proposed needling site | Radio | Options: No / Yes. |
| Contraindication and precaution screen | Needle phobia or previous adverse reaction to needling | Radio | Options: No / Yes. |
| Contraindication and precaution screen | Pacemaker or other implanted electrical device | Radio | Options: No / Yes. |
| Contraindication and precaution screen | Immune compromise, lymphoedema risk, or currently unwell with fever | Radio | Options: No / Yes. |
| Contraindication and precaution screen | Epilepsy or a history of seizures | Radio | Options: No / Yes. Needling has been associated with seizures in susceptible patients, so a yes answer needs a recorded decision below. |
| Contraindication and precaution screen | Diabetes, or reduced sensation or neuropathy in the area to be treated | Radio | Options: No / Yes. Slower healing and reduced sensation both raise the infection and injury risk. |
| Contraindication and precaution screen | History of keloid or raised scarring | Radio | Options: No / Yes. |
| Contraindication and precaution screen | Patient understands the information and can give their own consent | Radio | Options: Yes / No, a substitute decision maker is consenting. Record who consented in the practitioner section. |
| Contraindication and precaution screen | Practitioner's assessment of the screen above | Paragraph | Completed by the practitioner, not the patient: record any yes answer and the resulting decision to proceed, modify the site or technique, or not proceed. |
| Risks specific to dry needling | Risks explained | Checkboxes | Options: Temporary soreness or bruising at the needle site / Small risk of bleeding / Rare risk of fainting during or after the procedure / Rare risk of pneumothorax when needling near the chest wall / Rare risk of infection if aftercare advice is not followed. |
| Risks specific to dry needling | Aftercare advice given | Checkboxes | Options: Avoid vigorous exercise for the rest of the day / Report any unusual or worsening symptoms / Contact details for after hours concerns provided. |
| Consent and sign off | I confirm I have answered the screening questions honestly and completely | Checkboxes | Options: I confirm. |
| Consent and sign off | I consent to dry needling as explained above | Checkboxes | Options: I consent. |
| Consent and sign off | Patient name and date | Text | Connected question for name where available. |
| Consent and sign off | Signature | Text | Captured however your Cliniko account's patient form signature option is configured. |
Build it in Cliniko
- Go to Settings > Patient form templates as an Administrator, click Add template and name it Dry needling consent.
- Write the What dry needling is section as plain description text, and state directly that this form sits alongside the clinic's general treatment consent rather than replacing it, since a patient may otherwise assume one signature covers everything.
- Build the contraindication and precaution screen as individual Yes/No questions rather than one combined checklist, so a Yes answer is unambiguous and a practitioner reviewing the form later can see exactly which item was flagged.
- Add the practitioner's assessment field directly under the screen, and brief staff that this field is completed by the treating practitioner after discussing any Yes answer with the patient, not left blank or filled in by the patient themselves.
- Since Cliniko's native patient forms cannot hide questions or stop submission based on an answer, treat a Yes on any screening question as a manual prompt: the practitioner reviews it with the patient before the technique is used, and records that discussion in the assessment field, rather than relying on the form itself to flag or block anything.
- Send this form for completion in the clinic on the day dry needling is first proposed, rather than in the general new patient intake email, since not every patient will need it and a screen answered weeks before treatment can be out of date.
- Test the form on a sample patient with at least one Yes answer, and confirm the assessment field, risks and consent sections all read clearly together on the saved PDF before it is used with real patients.
AHPRA: The Australian Physiotherapy Association's guidance on dry needling describes an extensive list of precautions and contraindications as something practitioners cover in accredited dry needling training, rather than publishing a single fixed public list, so the categories in this template's screen are the ones most commonly covered in that training and in comparable health service policies, not a substitute for that training itself. The shared Code of conduct that the Physiotherapy Board of Australia applies still requires informed consent specific to this technique, which is what this separate form exists to record.
A specific consent, on top of the general one
Dry needling carries risks and contraindications that a general treatment consent does not cover in enough detail to count as informed consent for this specific technique. This template exists to sit alongside the general consent form built elsewhere in this cluster, not instead of it, which is why its opening section says so in plain language before any screening question is asked. A clinic using both forms ends up with two records: one showing the patient agreed to standard assessment and treatment in general, and one showing dry needling specifically was discussed, screened for and agreed to on a given date.
Why the screen is built as separate yes or no questions
The contraindication and precaution screen asks about bleeding disorders and anticoagulants, pregnancy, local skin conditions, needle phobia, implanted devices, immune compromise, epilepsy, diabetes or neuropathy, keloid scarring and capacity to consent as separate questions rather than one combined checklist, because a single missed tick in a long list is easy to overlook while a standalone Yes answer is hard to miss. The Australian Physiotherapy Association's own guidance on safe and competent dry needling describes a detailed list of precautions and contraindications as part of what accredited training covers, rather than as a single published checklist, so this template is honest about being a practical screening prompt built from commonly used categories, not a replacement for that training or for clinical judgement on the day.
The practitioner's field is what turns a screen into a decision
A Yes answer on its own does not stop treatment, since Cliniko's patient forms cannot enforce that automatically, so this template adds a field the practitioner completes after discussing any flagged item with the patient: proceed, modify the site or technique, or do not proceed. Recording that decision, rather than just the raw screening answers, is what shows a reviewer later that a positive screen was actually acted on rather than noted and ignored.
Sources
- The Australian Physiotherapy Association's guidance on dry needling states that an extensive list of precautions and contraindications is covered as part of accredited dry needling training, and that practitioners should undertake supervised practical training rather than learning the technique in an ad hoc way. Australian Physiotherapy Association (InMotion), checked 25 Sep 2026.
- Cliniko patient form templates are created under Settings > Patient form templates, are built from sections and individual questions including Multiple choice and Checkboxes, and do not support conditional logic that shows, hides or blocks a question based on an earlier answer. Cliniko Help, checked 25 Sep 2026.
- Cliniko supports sending a patient form to an individual patient as a one-off, separate from an automated booking confirmation, which suits a form only some patients need, such as a procedure specific consent. Cliniko Help, checked 25 Sep 2026.
- The shared Code of conduct for registered health practitioners, applied by the Physiotherapy Board of Australia, requires informed consent covering the nature of a proposed procedure and its material risks before it is performed. Physiotherapy Board of Australia, checked 25 Sep 2026.