Online Admission Form - Reliant Physical Therapy

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Date	02/27/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Ethan Green
Gender	Male
Date of Birth	09/23/2013
Email	Email hidden; Javascript is required.
Address	519 Wildberry Dr Pearl, Mississippi 39208 Map It
Home Phone	(601) 606-5985
Cell Phone	(601) 606-5985
Work Phone	(601) 606-5685
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?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	Lakeisha Green
Guarantor Gender	Female
Guarantor Date of Birth	07/23/1980
Guarantor Phone	(601) 606-5985
Guarantor Address	519 Wildberry Dr Pearl, Mississippi 39208 Map It
Insurance Information
Primary Insurance	Magnolia Health - MS CAN/MS CHIP
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Ethan Green
Primary Insurance: Insured Party DOB	09/23/2013
Primary Insurance: Insured Address	519 Wildberry Dr Pearl, Mississippi 39208 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	Lakeisha Green
Emergency Contact 1: Phone Number	(601) 606-5985
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Knee
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	02/22/2026
Patient Maritial Status	Single
Briefly describe your symptoms:	Knee pain
How did your symptoms start?	October:2025
What is your biggest complaint?	Hurts after running
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
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 Moderately
Pain
What is the WORST your pain gets on a 0 - 10 Scale?	8/10
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?	5/10 - Moderate Pain
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Mississippi sports med
Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
Please list a primary functional activity that you have difficulty performing.	Jumping
How much difficulty do you have in performing this first task?	5/10 - Moderate Difficulty
Please list a second functional activity that you have difficulty performing.	Runny
How much difficulty do you have in performing this second task?	7/10
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:
Referral Source
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;	Lakeisha Green
Signature