Online Admission Form - Reliant Physical Therapy

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Date	04/14/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	cashden lee patterson
Gender	Male
Date of Birth	06/18/2018
Email	Email hidden; Javascript is required.
Address	3211 virginia street pearl, Mississippi 39208 Map It
Home Phone	(601) 540-5677
Cell Phone	(601) 540-5677
Work Phone	(601) 540-5677
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	amber gillian patterson
Guarantor Gender	Female
Guarantor Date of Birth	04/08/1985
Guarantor Phone	(601) 540-5677
Guarantor Address	3211 virginia street pearl, Mississippi 39208 Map It
Insurance Information
Primary Insurance	Mississippi Medicaid
Primary Insurance ID Number	11264341200
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	cashden l patterson
Primary Insurance: Insured Party DOB	06/18/2026
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(601) 540-5677
Primary Insurance: Insured Address	3211 virginia street 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	amber patterson
Emergency Contact 1: Phone Number	(601) 540-5677
Emergency Contact 2: Name	ann sanders
Emergency Contact 2: Phone Number	(601) 624-3734
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	feet toe walkin
What side of the body will we be treating?	Both
Is this injury due to:	toe walking
Patient Maritial Status	Single
Briefly describe your symptoms:	toe walkin
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	Not at All A Little Bit
Pain
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	zimmerman
Medical History
Have you had any recent or unexplained weight loss?	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.
Referral Source
How did you find out about us?	Online Search
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;	Amber patterson
Signature