Course Registration Step 1 of 4 25% Integrated Dry Needling Intensive DetailsCourse Date* DD slash MM slash YYYY Course commencement date Location Name of city or townPersonal DetailsName* First Last Date of Birth* DD slash MM slash YYYY Email* Mobile*Preferred Daytime Phone Number*Address* Number Street City State / Province / Region Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name* First Last Emergency Contact Phone*GP Name* First Last GP's Practice Name* GP Phone*Profession Physiotherapist Chiropractor Osteopath Myotherapist Acupuncturist Medical Practitioner Massage Therapist Workplace Name* Workplace address* Number Street City State / Province / Region Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Workplace phone number*Are you registered with AHPRA?* Yes No AHPRA- Australian Health Practitioner Regulation AgencyAHPRA Registration Number* Professional Regulatory Body Name* Name of the professional body with whom you are registered to practiceRegistration Number* Registration or membership numberDo you hold you own professional indemnity and malpractice insurance?* Yes I am covered as an employee of the public health system I am covered by my policy held outside Australia I am studying and covered by the policy of my institution No Country in which policy is held* Professional Indemnity/Malpractice Insurer* Professional Indemnity/Malpractice Policy Number* Acupuncture/ Dry Needling background* None Integrated Dryneedling Myofascial trigger point dry needling Intramuscular stimulation (IMS) Traditional Chinese Medicine Japanese Meridian Therapy Choose whichever most closely represents your dry needling or acupuncture background Medical ScreeningAre you currently, or is there the possibility you may be pregnant?* No Yes Do you have diabetes?* No Yes Do you have a pacemaker?* No Yes Do you have a bleeding disorder?* No Yes Are you currently receiving medical treatment or awaiting follow up for the treatment of any cancer or tumours?* No Yes Do you have a Hep C, HIV or any other blood borne disease?* No Yes Do you have an acute immunological disorder (e.g. acute states of rheumatoid arthritis or systemic lupus erythema)?* No Yes Do you have known allergies to any metals? No Yes Some individuals may exhibit minor skin reactions as a result of contact with the alloys in the needles. You may wish to have any creams or medications you use with other reactions, with you on the course.* Not read Read, understood and actioned. Have you had any recent cardiac surgery?* No Yes You may be at an increased risk of infection as a recipient of dry needling. Please discuss this possibility with your specialist prior to participating in a dry needling course.* Not read Read, understood and actioned. I wish to participate in the course. Read, understood and actioned. I no longer wish to participate in the course Have you had any recent major dental surgery?* No Yes You may be at an increased risk of infection as a recipient of dry needling. Please discuss this possibility with your dental surgeon and medical practitioner prior to participating in a dry needling course.* Not read Read,understood and actioned. I wish to participate in the course. Read, understood and actioned. I no longer wish to participate in the course Do you have an incompetent heart valve or valve replacement?* No Yes Do you have a history of epilepsy?* No Yes Is your epilepsy medically controlled ?* No Yes Is your epilepsy stable?* No Yes Approximate date of last episode DD slash MM slash YYYY Are there known triggers?* No Yes Details of triggers*Do you get any warning of an impending episode?* No Yes Duration of warning before episode* Are there measures you can take to prevent the onset of an episode once you recognise the warning signs?* No Yes Details of preventative measures*Are you currently taking any medication other than an contraceptive?* No Yes Medication 1 Name* Medication 1 Dose* Medication 1 Condition* M1 Are you taking any other medications?* Yes No Medication 2 Dose* Medication 2 Condition* M2 Are you taking any other medications?* Yes No Medication 3 Dose* Medication 3 Condition* M3 Are you taking any other medications?* Yes No Please note any other medications, dose and conditions*Have you ever fainted or fitted when receiving injections, dry needling or acupuncture or giving blood?* No Yes Details of fainting or fitting*Include specific triggers, time of last event and duration of recovery or any lasting adverse effectsIs there any other reason you may feel that you are at an increased risk of injury or infection as a recipient of dry needling?* No Yes Details*Do you have any other physical or medical limitations or sensitivities that may be impacted by your participation in a dry needling course?* No Yes Details* Participant InformationAppropriate Clothing•Please wear underwear you are comfortable being assessed and treated in and be prepared to undress accordingly • You are welcome to wear loose stretchy shorts that allow access to the upper thigh and gluteal region • Please ensure bras are able to be undone at the back* Read Receiving dry needling techniques• Please expect to participate as a subject for technique demonstrations and for practical sessions in which you will both perform and receive the techniques in groups with your fellow course participants • This allows valuable experience to be gained from the perspective of patient as well as practitioner and ensures equal practice opportunity for all course participants* Read Physical preparation for course• Have sufficient sleep, conserve your energy in the days prior to your course • Avoid excessive consumption of alcohol the evening prior to, and during the course • Eat breakfast before attending the course each day • The spinal levels pertaining to the autonomic nervous system are those in the thoracic spine and upper lumbar spine. Stress and varying emotional states can alter autonomic nervous system activity. Mechanical or neurophysiological stimulation of these spinal regions, such as occurs in manual therapy or dry needling, can stimulate emotional responses. These may include temporary feelings of euphorioa or lability and occasionally syncope (fainting). These outcomes are not common but are more likely when an individual is overtired, jet-lagged, hungry, exhausted, extremely stressed or has consumed excessive alcohol.* Read Physical Considerations During the Course• During the course please take note if any course participants you are practicing with become pale, tearful, withdrawn or distant. If you feel light headed, tearful, overwhelmed, withdrawn or distant whilst a model for practical sessions please advise your group members. A short break from practice is required. A warm, sweet drink will also be beneficial. This phenomenon is very unlikely to occur in someone doing a two day course. It's most likely to occur during the final day of a four day programme. It has an estimated occurrence of 1 in 81 participants doing a four day training programme and affected individuals are usually those who have not observed the physical preparation for the course outlined previously.* Read Physical Considerations Following the Course• In addition to the treatment effects it shares with other manual therapy modalities there are some effects specific to dry needling that need to be considered as course participants as well as future practitioners of the modality. • The aim of dry needling in this approach to is to alter mechanical and neurophysiological loading of the tissue allowing improved movement patterns. As with any manual therapy modality that is effective, the recipient should realistically expect to experience some new or altered sensations as a result of altered tissue loading. This may include some temporary discomfort or soreness. • Although several treatments dosage of needling is received during a course, assimilation of altered loading often has a time component and follow up treatment is recommended to assist the process. Anyone experiencing any persistent, new discomfort following a course is recommended to seek follow up treatment to facilitate the change process* Read Self Care Post Course• The considerations for a course participant are beyond what is necessary for a patient receiving a single treatment as the amount of needling that is received during a two or four day course is far greater • The amount of needling you receive in a 4 day programme may be 12- 15 times as much as a single treatment would involve and may result in you feeling excessively tired. • Consider taking the day following a course off work to relax • You are advised not to undertake a long (greater than 1 hr) drive following a 4 day course as you may are likely to experience fatigue both as a result of concentrating in a course over a number of days and of having received a lot of needling.* Read WaiverService Provider – Andrew Hutton Physiotherapy Pty Ltd This may affect your legal rights and obligations. Please ensure you carefully read the following information before acknowledging your acceptance.* Read Acknowledgment of risks, dangers and obligationsI acknowledge that by participating in the dry needling course I am exposed to certain risks, therefore I ACKNOWLEDGE AND UNDERSTAND that whilst participating in the dry needling course • I will give special attention to all instructions oral and written and will query any matters that I do not understand. • I acknowledge that the instructions provided and safety precautions undertaken are a service to me and other participants and are not a guarantee of safety. • There may be no or inadequate facilities for treatment or transport of me if I am injured. • Other persons participating in the activity may cause me injury or damage to my property for which they may be liable. • I may cause injury to other persons or damage their property, for which I may be liable • I may cause loss or damage to property used/hired for which l may be liable. • I may be injured and/or suffer damage to my property as a result of my negligence or breach of contract. • I assume the risk of any injury (mental or physical), death or property damage resulting from my participation. • My participation in the dry needling course is voluntary and I have not been required by the Service Provider to engage in the activity.* I have read and understood this section Fitness to Participate• I am not under the influence of Drugs / Medication /mind altering substances, nor do I have any allergies or pre-existing medical condition that: ◦ Affect my understanding of safety instructions or ability to competently participate, and/or ◦ May be exacerbated by the activity and/or ◦ Otherwise affect my ability to participate in any aspect of this activity, and/or ◦ Prejudice the performance safety to myself and others.* I have read and understood this section Other• I agree to report all accidents or injuries, or loss or damage sustained by me to the Service Provider before I leave the site at which the activity is performed. • I agree that if I suffer any injury or illness that the Service Provider may arrange or provide evacuation, first aid, or medical treatment at my expense.* I have read and understood this section Image Release ConsentWe will at all times respect your modesty and ensure that you are aware that an image is being captured prior to doing so.Permission to Use Video or Photographic Images taken during the Integrated Dry Needling Intensive: I grant to Andrew Hutton Physiotherapy Pty Ltd/ TA Integrated Dry Needling, its representatives and employees the right to take photographs of me and my property in connection with the course.* I give my consent I do not give consent I authorize Andrew Hutton Physiotherapy Pty Ltd/TA Integrated Dry Needling, its assigns and transferees to copyright, use and publish the same in print and/or electronically.* I give my consent I do not give consent I agree thatAndrew Hutton Physiotherapy Pty Ltd/TA Integrated Dry Needling, its assigns and transferees may use images or video of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and online course or Web content.* I give my consent I do not give consent Release and Indemnity to The Service ProviderIn consideration of the acceptance of my payment for participating, except to the extent it is precluded by statutory law I agree to and indemnify the service provider as follows: • I release, indemnify and hold harmless the service provider, its officers, its employees, its servants and agents, from any actions against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of any injury, loss, damage or death caused to me or my property whether by negligence, breach of contract or in any circumstance whatsoever.I understand that by completing and submitting this form I am creating a legally binding document and agree to the terms above.* I have read and understood this section Type Name First Last Type name in lieu of signature
