Online Admission Form - Reliant Physical Therapy

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Date	03/02/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Jesse Wayne Shedd
Gender	Male
Date of Birth	05/15/1970
Email	Email hidden; Javascript is required.
Address	160 Excell drive Pearl, Mississippi 39208 Map It
Home Phone	(601) 331-0975
Cell Phone	(601) 331-0978
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	Blue Cross Blue Shield
Primary Insurance ID Number	GMB807881041
Primary Insurance: Patient's Relationship to Insured Party	Spouse
Primary Insurance: Insured Party Name	Jeannine Lynn Shedd
Primary Insurance: Insured Party DOB	10/06/1975
Primary Insurance: Insured Address	160 Excell drive 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	Jeannine Shedd
Emergency Contact 1: Phone Number	(601) 331-1097
Emergency Contact 2: Name	Lucille Shedd
Emergency Contact 2: Phone Number	(601) 212-3830
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Neck
What side of the body will we be treating?	Neck
Is this injury due to:	Other
Patient Maritial Status	Married
Briefly describe your symptoms:	Severe neck pain
How did your symptoms start?	Suddenly
What is your biggest complaint?	Pain
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Very 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	Moderately
Pain
Where is the location of your pain?	Nevk
What is the WORST your pain gets on a 0 - 10 Scale?	9/10
What is the BEST your pain gets on a 0 - 10 Scale?	3/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	3/10
Pain Description (Please check all that apply)	Sharp Throbbing
Employment
Are you employed?	Yes
Patient Employer	Self
Patient Employment Status	Full Time
Duty Level of Work:	Heavy
Are you currently working?	Yes - Regular Duty
Patient Employer Address	Mississippi Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Jacob Hoffman
Medical History
Do you have any of the following medical conditions? (Check all that apply)	I have no significant Medical History
Have you had any recent or unexplained weight loss?	No
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;	Jesse Shedd
Signature