Online Admission Form - Reliant Physical Therapy

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Date	05/19/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Georgia H Journey
Gender	Female
Date of Birth	02/06/1951
Email	Email hidden; Javascript is required.
Address	911 Dr Martin Luther King Dr Kosciusko, Mississippi 39090 Map It
Cell Phone	(662) 392-0704
Which clinic will you receive treatment at?	Kosciusko
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Humana
Primary Insurance ID Number	H77176780
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Georgia H Journey
Primary Insurance: Insured Party DOB	02/06/1951
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	911 Dr Martin Luther King Dr 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	William Journey
Emergency Contact 1: Phone Number	(601) 750-5684
Emergency Contact 2: Name	Martin Journey
Emergency Contact 2: Phone Number	(662) 770-2009
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Hand
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	03/20/2026
Is this injury due to:	Other
Patient Maritial Status	Married
How did your symptoms start?	When I fractured my hand.
What is your biggest complaint?	Pain and stiffness.
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Very Good
Home Layout	One Story Home Shower Stall
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	Moderately
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?	In my fingers and hand.
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?	2/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	2/10
Pain Description (Please check all that apply)	Dull/Achy Throbbing
Employment
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Klaye Clardy, FNP
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?	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.	Lasortan
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Vitamin D
Please list any allergies you may have and your bodies response to this allergy.	Sulfur
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	4/2002
What are your goals from physical therapy?	Full use of my hand
Please list a primary functional activity that you have difficulty performing.	Anything that requires both hands.
How much difficulty do you have in performing this first task?	8/10
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?	Doctor
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;	Georgia Journey
Signature