Online Admission Form - Reliant Physical Therapy

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Date	03/09/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Keith Speights
Gender	Male
Date of Birth	08/31/1966
Email	Email hidden; Javascript is required.
Address	141 Woodlands Green Dr. Brandon, Mississippi 39047 Map It
Cell Phone	(601) 506-5737
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
Guarantor Address	Brandon, Mississippi 39047 Map It
Insurance Information
Primary Insurance	Blue Cross Blue Shield
Primary Insurance ID Number	YAU868975370M
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Address	141 Woodlands Green Dr. Brandon, Mississippi 39047 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	Lisa Speights
Emergency Contact 1: Phone Number	(601) 506-5892
Emergency Contact 2: Name	Hannah Sheridan
Emergency Contact 2: Phone Number	(769) 232-7422
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Sciatic pain
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	02/09/2026
Is this injury due to:	Other
Patient Maritial Status	Married
Briefly describe your symptoms:	Intermittent pain in right leg
How did your symptoms start?	The pain started out of the blue with no apparent reason
What is your biggest complaint?	It often hurts to walk and stand
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Very Good
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?	Right leg
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?	0/10 - No Pain
Pain Description (Please check all that apply)	Sharp Numbness/Tingling Intermittent
What makes your pain worse?	Standing Walking Bending
What makes your pain better?	Sitting, lying down
Employment
Are you employed?	Yes
Patient Employer	Self employed
Occupation	Writer
Patient Employment Status	Full Time
Duty Level of Work:	Light
Are you currently working?	Yes - Regular Duty
Patient Employer Address	141 Woodlands Green Dr. Brandon, Mississippi 39047 Map It
Are you disabled or currently on disability?	No
Medical History
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Atorvastatin
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Preservation AREDs 2 vitamins
What are your goals from physical therapy?	Reduce pain
Please list a primary functional activity that you have difficulty performing.	Walking
How much difficulty do you have in performing this first task?	7/10
Please list a second functional activity that you have difficulty performing.	Standing
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:
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?	Family
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;	Keith Speights
Signature