Online Admission Form - Reliant Physical Therapy

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Date	08/21/2025
Patient Information
Formal Name (as on Insurance Card or Driver License)	Jan Amelia Sanford
Nickname/Name you liked to be called?	Jan
Gender	Female
Date of Birth	06/06/1951
Email	Email hidden; Javascript is required.
Address	100 Cannon Run Canton, Mississippi 39046 Map It
Cell Phone	(601) 573-2422
Would you like an email or text message reminder about your appointments?	Yes
What type of reminder(s) would you like?	Text Message (2-3 hrs prior to appointment)
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	United HealthCare
Primary Insurance ID Number	99105037800
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Jan Amelia Sanford
Primary Insurance: Insured Party DOB	06/06/1951
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	100 Cannon Run Canton, Mississippi 39046 Map It
Do you have a secondary Insurance.	No
Is this a worker's compensation or other accident claim?	No
Emergency Contacts
Emergency Contact 1: Name	Michelle Cupstid
Emergency Contact 1: Phone Number	(601) 573-2422
Emergency Contact 2: Name	Brittney Cupstid
Emergency Contact 2: Phone Number	(601) 573-2567
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Neck and shoulders
What side of the body will we be treating?	Neck
Is this injury due to:	Other
Patient Maritial Status	Other
Briefly describe your symptoms:	MRI should plaque in neck
How did your symptoms start?	Not sure
What is your biggest complaint?	Can’t hold neck up always looking down
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Good
Home Layout	One Story Home
Living Situation	Lives with Family
Do you now or have you ever smoked?	No
Do you have a history of falling?	No
Have you had prior physical therapy, occupational therapy or chiropractic treatment this year?	No
Current Functional Limitations
How much have your symptoms interfered with your usual daily activities	A Little Bit
Pain
Where is the location of your pain?	Neck
What is the WORST your pain gets on a 0 - 10 Scale?	1/10
What is the BEST your pain gets on a 0 - 10 Scale?	0/10 - No Pain
What is your pain RIGHT NOW on a 0 - 10 Scale?	0/10 - No Pain
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Michael Winkelmann MD
Medical History
Have you had any diagnostic imaging studies for this injury?	MRI
Have you had any recent or unexplained weight loss?	Yes
Are you taking any of the following?	Prescription Medications Vitamin/Mineral/Dietary Supplements
What are your goals from physical therapy?	For my neck not to hang down
How much difficulty do you have in performing this first task?	1/10
How much difficulty do you have in performing this third task?	10/10 - No Problem or Difficulty Performing
Are you currently receiving home health services?	No
Consent for Treatment
Consent for Treatment	I, the patient/guardian, acknowledge that I am of a sound mind and physically/mentally able to give consent for my/my dependent's care. I hereby give consent to receive outpatient physical therapy services as deemed necessary by the therapist(s) on duty at Reliant, Inc. I am aware that the practice of physical therapy is not an exact science and I acknowledge that no guarantees have been made regarding my treatments, results or outcomes. I understand that in some cases, treatment techniques may actually increase my pain. I understand that proper evaluation and treatment may require bodily contact, touching and/or direct contact by the therapists. I have reviewed the Patient Consent Form, Dry Needling Consent Form and Privacy Policy at the hyperlinks below. I am aware that as the patient/guardian I have the right to decline and/or refuse any portion of my treatment that I decide not to participate in.
ELECTRONIC MONTHLY NEWSLETTER:
Electronic Monthly Newsletter	In an ongoing effort to provide our patients with continued education and the latest healthcare information you may choose to receive monthly emails from our company. You may opt-out at any time, if you prefer to receive our monthly newsletter please sign up above on our online admission form.
Referral Source
How did you find out about us?	Doctor
Certification Statement
Patient/Guardian Signature	By signing below, I certify that I am the patient or have legal rights to sign on the patient's behalf. Furthermore, I have read and understand the statements and policies that have been stated above. I also certify that I have provided correct information to the best of my knowledge. I hereby authorize payment directly to Reliant, Inc. for medical services rendered. I authorize the release of my medical information deemed necessary in the processing of my medical claims.
Form Completed By;	Jan Sanford
Signature