Online Admission Form - Reliant Physical Therapy

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Date	05/15/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Alicia Marengo Herring
Nickname/Name you liked to be called?	Alicia
Gender	Female
Date of Birth	10/02/1978
Email	Email hidden; Javascript is required.
Address	403 Scarlet Cv Flowood, Mississippi 39232 Map It
Cell Phone	(662) 719-9878
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	CMAM61195658
Primary Insurance: Patient's Relationship to Insured Party	Spouse
Primary Insurance: Insured Party Name	Ben Herring
Primary Insurance: Insured Party DOB	11/27/1969
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	403 Scarlet Cv Flowood, Mississippi 39232 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	Ben Herring
Emergency Contact 1: Phone Number	(662) 588-0143
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Neck/shoulder
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	06/15/2024
Is this injury due to:	Fall
Patient Maritial Status	Married
Briefly describe your symptoms:	Stiffness, pain, tingling down right arm off and on.
How did your symptoms start?	Fell onto head and shoulder
What is your biggest complaint?	Sleeping is horrible.
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	A Little Bit
Please check or describe any limitations you have experienced in your Self Care:	Sleeping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use
Pain
Where is the location of your pain?	Neck and shoulder
What is the WORST your pain gets on a 0 - 10 Scale?	10/10 - Severe Pain
What is the BEST your pain gets on a 0 - 10 Scale?	5/10 - Moderate Pain
What is your pain RIGHT NOW on a 0 - 10 Scale?	8/10
Pain Description (Please check all that apply)	Dull/Achy Numbness/Tingling Constant Worse at night while sleeping
What makes your pain worse?	Sitting Standing Lying Down
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr. Berry
Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Lexapro & Wellbutrin
What are your goals from physical therapy?	Lessened pain
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?	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;	Alicia Herring
Signature