Janet G. Travell, MD Seminar Series

Dry Needling (DN) Program
Registration

Sample Waiver
I, ________________________ , understand that the course offered by Myopain Seminars is a participatory seminar program in which all persons attending the courses are expected to practice on each other. This means that I will allow my fellow participants as well as the workshop instructors to place solid filament needles into various muscles throughout my body during the seminar.

I understand that although the risk of any serious harm is minimal, nevertheless there is the possibility of injury. Specifically, placing solid filament needles into the body could possibly result in puncture of an organ such as the lung, the puncture of a vessel (artery or vein), or a nerve injury. Hematomas may occur and bruising may result. It is also possible that I may faint.

I understand the risk of complication, though small, is real. I hereby hold Myopain Seminars, the program directors, and instructors harmless for any injury sustained from dry needling during the course. Also, I hereby hold Myopain Seminars, the program directors, and instructors harmless for any injury sustained from dry needling or injection techniques in my own practice.
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Signature and Date
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Witness Signature and Date