Medical History Form

This is a mandatory intake form for patients of CoachAmyPT to assess a review of systems. It is an integral part of the diagnostic process. To save time at your appointment, please fill this out before your evaluation.

Dry Needling Forms

All patients receiving dry needling services at CoachAmyPT must read and sign the dry needling consent to treat form. Patients with Blue KC insurance receiving dry needling must also sign a consent to pay out-of-pocket for uncovered services.

Consent to Dry Needling Form

Blue KC out-of-pocket consent form: Dry Needling

Wellness Patients with Medicare as Primary.

CoachAmyPT is out of network with Medicare. Patients with Medicare as their primary health insurance wishing to receive services with CoachAmyPT are required to attest to their free will decision to pay out-of-pocket for services.

Medicare Out-of-Pocket Exemption FOrm

High-Intensity Laser Therapy Forms

All patients receiving HILT services at CoachAmyPT must read and sign the consent to treat form. Patients with Blue KC insurance receiving laser must also sign a consent to pay out-of-pocket for uncovered services.

Consent to Laser Form

Blue KC Out-of-pocket consent form: Laser

Blood Flow Restriction Training Consent form

All patients receiving BFRT services at CoachAmyPT must read and sign the consent to treatment form.

Consent to Blood Flow Restriction Training Form