Online Admission Form - Reliant Physical Therapy

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Date	04/30/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Buford Glynn Hannah
Nickname/Name you liked to be called?	Glynn
Gender	Male
Date of Birth	09/02/1963
Email	Email hidden; Javascript is required.
Address	121 Crossview Pl Brandon, Mississippi 39047 Map It
Cell Phone	(601) 201-9370
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	YAU869060199M
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Address	Mississippi 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	Natalie Hannah
Emergency Contact 1: Phone Number	(769) 240-8443
Emergency Contact 2: Name	Beau Hannah
Emergency Contact 2: Phone Number	(601) 668-0203
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Hip and back
What side of the body will we be treating?	Right
Is this injury due to:	62 years of self abuse
Patient Maritial Status	Married
Briefly describe your symptoms:	Right hip hurting standing or sitting
How did your symptoms start?	On and on years ago but recently about a month ago
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
Current Functional Limitations
How much have your symptoms interfered with your usual daily activities	Quite a Bit
Please check or describe any limitations you have experienced in your Mobility:	Walking at Home
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Recreation
Pain
Where is the location of your pain?	Right hip and back
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?	1/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	3/10
Pain Description (Please check all that apply)	Sharp Constant Worse in PM
What makes your pain worse?	Sitting Bending Coughing/Sneezing
What makes your pain better?	Meds
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Donald Baker
Medical History
Do you have any of the following medical conditions? (Check all that apply)	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
Please list any allergies you may have and your bodies response to this allergy.	Penicillin
What are your goals from physical therapy?	To avoid surgery
Please list a primary functional activity that you have difficulty performing.	Exercising
How much difficulty do you have in performing this first task?	7/10
Are you currently receiving home health services?	Yes
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?	Previous client
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;	Buford Hannah
Signature