Online Admission Form - Reliant Physical Therapy

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Date	03/03/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Latham Christopher Bynum
Nickname/Name you liked to be called?	Latham
Gender	Male
Date of Birth	01/28/2008
Email	Email hidden; Javascript is required.
Address	107 Winchester Lane 107 Winchester Lane, Mississippi 39042 Map It
Cell Phone	(601) 383-3397
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.	Guardian
Guarantor Name	Robert Christopher Bynum
Guarantor Gender	Male
Guarantor Date of Birth	09/30/1972
Guarantor Phone	(601) 624-5436
Guarantor Address	107 Winchester Lane 107 Winchester Lane, Mississippi 39042 Map It
Insurance Information
Primary Insurance	United HealthCare
Primary Insurance ID Number	914883953
Primary Insurance: Patient's Relationship to Insured Party	Child
Primary Insurance: Insured Party Name	Robert Christopher Bynum
Primary Insurance: Insured Party DOB	09/30/1972
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(877) 842-3210
Primary Insurance: Insured Address	107 Winchester Lane 107 Winchester Lane, Mississippi 39042 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	Brittney Bynum
Emergency Contact 1: Phone Number	(601) 540-1580
Emergency Contact 2: Name	Chris Bynum
Emergency Contact 2: Phone Number	(601) 624-5436
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Arm
What side of the body will we be treating?	Right
Is this injury due to:	Sports Related
Patient Maritial Status	Single
Briefly describe your symptoms:	Arm pain
What is your biggest complaint?	Soreness
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
Pain
What is the WORST your pain gets on a 0 - 10 Scale?	2/10
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?	2/10
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
Medical History
Have you had any recent or unexplained weight loss?	No
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	NA
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	NA
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	Creatine
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Zinc, Vit D, Multi Vit
What are your goals from physical therapy?	Stay pain free
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;	Chris Bynum
Signature