Online Admission Form - Reliant Physical Therapy

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Date	04/22/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	LAURA ROBINSON NELSON
Gender	Female
Date of Birth	05/10/1975
Email	Email hidden; Javascript is required.
Address	706 NORTHDALE PLACE BRANDON, Mississippi 39047 Map It
Home Phone	(601) 540-6335
Cell Phone	(601) 540-6335
Work Phone	(769) 230-8335
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Cigna
Primary Insurance ID Number	112060448
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	LAURA NELSON
Primary Insurance: Insured Party DOB	05/10/1975
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	706 NORTHDALE PLACE 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	JAMES NELSON
Emergency Contact 1: Phone Number	(601) 540-8838
Emergency Contact 2: Name	LAURA NELSON
Emergency Contact 2: Phone Number	(769) 230-8335
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	NECK, SHOULDERS
What side of the body will we be treating?	Neck
Is this injury due to:	Other
Patient Maritial Status	Married
Briefly describe your symptoms:	I have had migraines since my early 20s. - I tend to hold stress in my neck and shoulders which makes my migraines worse.
What is your biggest complaint?	knots in my neck
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Good
Home Layout	One Story Home
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?	Yes
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?	neck and shoulders
What is the WORST your pain gets on a 0 - 10 Scale?	7/10
What is the BEST your pain gets on a 0 - 10 Scale?	2/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	7/10
Pain Description (Please check all that apply)	Dull/Achy Throbbing
What makes your pain better?	massage, heat
Employment
Are you employed?	Yes
Patient Employer	The Transplant Pharmacy DBA CareDx Pharmacy
Occupation	Pharmacist
Patient Employment Status	Full Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	630 LAKELAND EAST DR SUITE B FLOWOOD, Mississippi 39232 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	GINA BURGE
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Diabetes Type 2 High Blood Pressure
Have you had any diagnostic imaging studies for this injury?	MRI
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Over the Counter Medications Vitamin/Mineral/Dietary Supplements
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	will bring a list
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	will bring list
Please list any allergies you may have and your bodies response to this allergy.	NKDA
What are your goals from physical therapy?	MYOFASCIAL THERAPY TO RELEASE THE KNOTS AND TENSION IN MY NECK AND SHOULDERS
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;	LAURA R. NELSON
Signature