Online Admission Form - Reliant Physical Therapy

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Date	05/20/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Bowen Halbert Smith
Nickname/Name you liked to be called?	Bowen
Gender	Male
Date of Birth	05/03/2016
Email	Email hidden; Javascript is required.
Address	127 Buckingham Place Brandon, Mississippi 39047 Map It
Home Phone	(601) 917-7270
Cell Phone	(601) 917-7270
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	Elizabeth Ann Smith
Guarantor Gender	Female
Guarantor Date of Birth	04/05/1988
Guarantor Phone	(601) 917-7270
Guarantor Address	127 Buckingham Place Brandon, Mississippi 39047 Map It
Insurance Information
Primary Insurance	Blue Cross Blue Shield
Primary Insurance ID Number	YAX 868588897M
Primary Insurance: Patient's Relationship to Insured Party	Child
Primary Insurance: Insured Party Name	Elizabeth Ann Smith
Primary Insurance: Insured Party DOB	04/05/1988
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Phone	(601) 917-7270
Primary Insurance: Insured Address	127 Buckingham Place 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	Matt Smith
Emergency Contact 1: Phone Number	(601) 616-9090
Emergency Contact 2: Name	Elizabeth Smith
Emergency Contact 2: Phone Number	(601) 917-7270
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back
What side of the body will we be treating?	Back
Date of Injury or when your pain began.	04/12/2026
Is this injury due to:	Sports Related
Patient Maritial Status	Single
Briefly describe your symptoms:	Cramping pain in middle of lower back then moves across back waistline.
How did your symptoms start?	Hitting in batting cage
What is your biggest complaint?	Back pain
How often do you experience your symptoms?	Occasionally (26-50% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
Home Layout	One Story Home Combo Tub/Shower
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
Pain
Where is the location of your pain?	Lower Back along waistline
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?	0/10 - No Pain
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Sharp
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Patrick Wright
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 diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
Please list any allergies you may have and your bodies response to this allergy.	Penicillin- Severe rash
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?	Friend of Nick Gunter
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;	Elizabeth Smith
Signature