Online Admission Form - Reliant Physical Therapy

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Date	04/29/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Alex Randolph Williams
Nickname/Name you liked to be called?	Alex
Gender	Male
Date of Birth	10/11/1962
Email	Email hidden; Javascript is required.
Address	160 Lakeview Rd Brandon, Mississippi 39047 Map It
Home Phone	(601) 316-8971
Cell Phone	(601) 316-8971
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Blue Cross Blue Shield
Primary Insurance ID Number	Fxf925a22784
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Alex Randolph Williams
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	160 Lakeview Rd 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
Basic Information
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	04/14/2026
Is this injury due to:	Other
Patient Maritial Status	Married
Briefly describe your symptoms:	Plantar Facia
How did your symptoms start?	Suddenly
What is your biggest complaint?	Pain walking
How often do you experience your symptoms?	Constantly (76-100% of the time)
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	Quite a Bit
Pain
Where is the location of your pain?	Heel
What is the WORST your pain gets on a 0 - 10 Scale?	6/10
What is the BEST your pain gets on a 0 - 10 Scale?	3/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Burrows
Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
What are your goals from physical therapy?	No pain
Please list a primary functional activity that you have difficulty performing.	Walking
How much difficulty do you have in performing this first 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?	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;	Alex Williams
Signature