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)	Conner E Williamson
Gender	Male
Date of Birth	10/05/2011
Email	Email hidden; Javascript is required.
Address	2621 Attala Road 4026 Kosciusko, Mississippi 39090 Map It
Home Phone	(662) 273-3462
Cell Phone	(662) 273-3462
Which clinic will you receive treatment at?	Kosciusko
Guarantor Information
Patient Relationship to Guarantor.	mother
Guarantor Name	Ashley Williamson
Guarantor Gender	Female
Guarantor Date of Birth	01/25/1982
Guarantor Phone	(662) 273-3462
Guarantor Address	2621 Attala Road 4026 Kosciusko, Mississippi 39090 Map It
Insurance Information
Primary Insurance	Aetna
Primary Insurance ID Number	005011618
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Conner Williamson
Primary Insurance: Insured Party DOB	10/05/2011
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(662) 273-3462
Primary Insurance: Insured Address	2621 Attala Road 4026 Kosciusko, Mississippi 39090 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	Ashley Williamson
Emergency Contact 1: Phone Number	(662) 273-3462
Emergency Contact 2: Name	John Williamson
Emergency Contact 2: Phone Number	(662) 242-3209
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	hips
What side of the body will we be treating?	Both
Date of Injury or when your pain began.	03/26/2026
Is this injury due to:	Sports Related
Patient Maritial Status	Single
Briefly describe your symptoms:	hip pain while running.
How did your symptoms start?	Sprinting at trackmeet
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
Home Layout	One Story Home
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
Pain
Where is the location of your pain?	hips
What is the WORST your pain gets on a 0 - 10 Scale?	4/10
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?	2/10
Pain Description (Please check all that apply)	Sharp Shooting
What makes your pain worse?	Going Up Stairs Bending
What makes your pain better?	resting
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Tyler Brown
Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	zyrtec
Please list any allergies you may have and your bodies response to this allergy.	penecillin/ hives
What are your goals from physical therapy?	to relieve hip pain
Please list a primary functional activity that you have difficulty performing.	running
How much difficulty do you have in performing this first task?	0/10 - Unable to Perform
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?	Other
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;	Ashley Williamson
Signature