Online Admission Form - Reliant Physical Therapy

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Date	04/24/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Will Lyle Tolbert
Gender	Male
Date of Birth	07/01/1992
Email	Email hidden; Javascript is required.
Address	314 Afton Dr Brandon, Mississippi 39042 Map It
Cell Phone	(601) 214-8639
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	United HealthCare
Primary Insurance ID Number	931110551
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Will Lyle Tolbert
Primary Insurance: Insured Party DOB	07/01/1992
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	314 Afton Dr Brandon, 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	Madison Tolbert
Emergency Contact 1: Phone Number	(601) 259-3188
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back
What side of the body will we be treating?	Right
Is this injury due to:	Sports injury
Patient Maritial Status	Married
Briefly describe your symptoms:	Sharp local pain from bulging disc L3-L4
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	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?	Yes
Current Functional Limitations
How much have your symptoms interfered with your usual daily activities	Moderately
Pain
Where is the location of your pain?	Lower right back
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?	2/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	4/10
Employment
Are you employed?	Yes
Patient Employer	Precision Spine
Occupation	Manufacturing engineer
Patient Employment Status	Full Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	2040 Executive Dr Pearl, Mississippi 39208 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Andrew Sharp
Medical History
Have you had any diagnostic imaging studies for this injury?	MRI
Have you had any recent or unexplained weight loss?	No
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Left shoulder
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
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;	Will Tolbert
Signature