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* 1. Client name (surname, first name)

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* 2. Who reviewed this consent form with you today?

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* 3. Intramuscular Stimulation (IMS) uses fine and flexible needles to release shortened bands of muscle caused by abnormal functioning of the nervous system. No drugs are injected.

IMS is a valuable as treatment for chronic pain. Like any medical procedure, there are possible complications. While these complications are rare in occurence, they are real and must be considered prior to giving consent to the procedure.

Any time a needle is used, there is a risk of infection. Our Physiotherapists use new, disposable, sterile needles thereby minimizing any risk of infection.

A needle may be placed inadvertently in an artery, nerve or vein. If an artery or vein is punctured with the needle, a hematoma (bruise) will develop. If a nerve is punctured, it may cause paresthesia (a prickling sensation) which may continue for days. 

When a needle is placed close to the chest wall, there is a rare possibility of pneumothorax (air in the chest cavity). Our Physiotherapists use their anatomical knowledge and safe needling techniques to minimize risk of pneumothorax.

Fortunately, all of these complications are not fatal and are readily reversible.

Clients are requested to inform practioners about conditions such as pregnancy, pace makers, use of blood thinners, breast implants, or the presence of artificial joints prior to treatment.