Online Admission Form - Reliant Physical Therapy

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Date	05/21/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Mrs Theresa McNair
Nickname/Name you liked to be called?	Theresa
Gender	Female
Date of Birth	08/03/1966
Email	Email hidden; Javascript is required.
Address	4141 Attala Road 4112 Sallis, Mississippi 39160 Map It
Cell Phone	(601) 506-6519
Work Phone	(601) 607-6380
Work Phone Extension (if applicable)	6380
Which clinic will you receive treatment at?	Kosciusko
Guarantor Information
Patient Relationship to Guarantor.	Spouse
Guarantor Name	Gregory McNair
Guarantor Gender	Male
Guarantor Date of Birth	10/14/1966
Guarantor Phone	(662) 633-9578
Guarantor Address	4141 Attala Road 4112 Sallis, Mississippi 39160 Map It
Insurance Information
Primary Insurance	Blue Cross Blue Shield
Primary Insurance: Patient's Relationship to Insured Party	Spouse
Primary Insurance: Insured Party Name	Anthem Gregory ETKAN3416883
Primary Insurance: Insured Party DOB	10/14/1966
Primary Insurance: Insured Phone	(662) 633-9578
Primary Insurance: Insured Address	4141 Attala Road 4112 Sallis, Mississippi 39160 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	Gregory McNair
Emergency Contact 1: Phone Number	(662) 633-9578
Emergency Contact 2: Name	Frank Williams
Emergency Contact 2: Phone Number	(662) 582-5049
Basic Information
What side of the body will we be treating?	Left
Patient Maritial Status	Married
Briefly describe your symptoms:	No pain just a weird like something crawling on me
How did your symptoms start?	just 2 weeks ago
What is your biggest complaint?	its weird feeling
How often do you experience your symptoms?	Intermittently (0-25% 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
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
What is the WORST your pain gets on a 0 - 10 Scale?	0/10 - No 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?	0/10 - No Pain
Employment
Are you employed?	Yes
Patient Employer	Vertex
Occupation	Senior Accountant
Patient Employment Status	Full Time
Duty Level of Work:	Light
Are you currently working?	Yes - Regular Duty
Patient Employer Address	Vertex Madison, Mississippi Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr Green
Medical History
Have you had any recent or unexplained weight loss?	No
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Ozempiz, Thyrod, Blood pressure, cholesterol
Please list any allergies you may have and your bodies response to this allergy.	Penicillin
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	N/A
What are your goals from physical therapy?	Feel better
Please list a primary functional activity that you have difficulty performing.	N/A
How much difficulty do you have in performing this first task?	10/10 - No Problem or Difficulty Performing
How much difficulty do you have in performing this second task?	10/10 - No Problem or Difficulty Performing
How much difficulty do you have in performing this third task?	10/10 - No Problem or Difficulty Performing
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?	Tina McNeal
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;	Theresa McNair
Signature