Online Admission Form - Reliant Physical Therapy

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Date	04/17/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	LaTina Atterberry Gray
Gender	Female
Date of Birth	07/03/1981
Email	Email hidden; Javascript is required.
Address	418 Silver Hill Pearl, Mississippi 39208 Map It
Home Phone	(601) 896-4634
Cell Phone	(601) 896-4634
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	Zola Gray
Guarantor Gender	Female
Guarantor Date of Birth	11/05/2013
Guarantor Address	418 Silver Hill Pearl, Mississippi 39208 Map It
Insurance Information
Primary Insurance	Aetna
Primary Insurance: Patient's Relationship to Insured Party	Child
Primary Insurance: Insured Party Name	LATINA GRAY
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Phone	(601) 896-4634
Primary Insurance: Insured Address	418 Silver Hill 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	Eric Gray
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Foot
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	03/04/2026
Patient Maritial Status	Divorced Other
How did your symptoms start?	Surgery
What is your biggest complaint?	Walking on foot
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	Yes
Date of Surgery	03/04/2026
Surgical Procedure:	Bilateral pes planus
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	Quite a Bit Extremely
Pain
What is the WORST your pain gets on a 0 - 10 Scale?	0/10 - No Pain
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
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr. Leitch
Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
How much difficulty do you have in performing this first task?	5/10 - Moderate Difficulty
How much difficulty do you have in performing this second task?	5/10 - Moderate Difficulty
How much difficulty do you have in performing this third task?	5/10 - Moderate Difficulty
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.
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;	LATINA GRAY
Signature