Online Admission Form - Reliant Physical Therapy

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Date	05/16/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Cooper Richard Calvert
Nickname/Name you liked to be called?	Cooper
Gender	Male
Date of Birth	09/28/2010
Email	Email hidden; Javascript is required.
Address	318 Avalon Way Brandon, Mississippi 39047 Map It
Home Phone	(601) 421-0552
Cell Phone	(601) 926-7417
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Guardian
Guarantor Name	Matthew John Calvert
Guarantor Gender	Male
Guarantor Date of Birth	04/14/1978
Guarantor Phone	(601) 421-0552
Guarantor Address	318 Avalon Way Brandon, Mississippi 39047 Map It
Insurance Information
Primary Insurance	United HealthCare
Primary Insurance ID Number	G44912347
Primary Insurance: Patient's Relationship to Insured Party	Child
Primary Insurance: Insured Party Name	Matthew John Calvert
Primary Insurance: Insured Party DOB	04/14/1978
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(601) 421-0552
Primary Insurance: Insured Address	318 Avalon Way 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
Emergency Contact 1: Name	Mandi Calvert
Emergency Contact 1: Phone Number	(601) 214-2331
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Hip, leg
What side of the body will we be treating?	Both
Is this injury due to:	Sports Related
Patient Maritial Status	Single
Briefly describe your symptoms:	How to get stronger for kicking
Did you have surgery?	No
Rate your overall health:	Excellent 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	Not at All
Pain
Employment
Are you employed?	Yes
Patient Employer	Flying Dolly’s
Occupation	Snowball Marker
Patient Employment Status	Part Time
Duty Level of Work:	Medium
Are you currently working?	Yes, but on Modified or Light Duty
Patient Employer Address	Mississippi Map It
Are you disabled or currently on disability?	No
Medical History
Do you have any of the following medical conditions? (Check all that apply)	I have no significant Medical History
Have you had any recent or unexplained weight loss?	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?	Friendship
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;	Matthew Calvert
Signature