Online Admission Form - Reliant Physical Therapy

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Date	05/26/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	William Haddon McLeod
Gender	Male
Date of Birth	04/14/2004
Email	Email hidden; Javascript is required.
Address	3838 Sleepy Hollow Drive Jackson, Mississippi 39211 Map It
Home Phone	(601) 500-2123
Cell Phone	(601) 500-2123
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	Scott Haddon McLeod
Guarantor Gender	Male
Guarantor Date of Birth	04/13/1973
Guarantor Phone	(601) 613-6636
Guarantor Address	3838 Sleepy Hollow Drive Jackson, Mississippi 39211 Map It
Insurance Information
Primary Insurance	Blue Cross Blue Shield
Primary Insurance ID Number	YAX 869406540M
Primary Insurance: Patient's Relationship to Insured Party	Child
Primary Insurance: Insured Party Name	Scott Haddon McLeod
Primary Insurance: Insured Party DOB	04/13/1973
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(601) 613-6636
Primary Insurance: Insured Address	3838 Sleepy Hollow Drive Jackson, Mississippi 39211 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	Paige Mcleod
Emergency Contact 1: Phone Number	(601) 953-0765
Emergency Contact 2: Name	Scott McLeod
Emergency Contact 2: Phone Number	(601) 613-6663
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?	Both
Is this injury due to:	Sports Related
Patient Maritial Status	Single
Briefly describe your symptoms:	Back problems over time
How did your symptoms start?	Pain
What is your biggest complaint?	Pain
How often do you experience your symptoms?	Occasionally (26-50% of the time)
Did you have surgery?	Yes
Rate your overall health:	Good
Living Situation	Lives Alone
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?	Yes
Current Functional Limitations
How much have your symptoms interfered with your usual daily activities	Moderately
Pain
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?	1/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	3/10
Employment
Are you employed?	Yes
Patient Employer	RWW
Occupation	Sales
Patient Employment Status	Full Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	Mississippi Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Amundson
Medical History
Have you had any diagnostic imaging studies for this injury?	MRI
Have you had any recent or unexplained weight loss?	No
How much difficulty do you have in performing this first task?	2/10
How much difficulty do you have in performing this second task?	1/10
How much difficulty do you have in performing this third task?	3/10
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?	Online Search
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;	Haddon McLeod
Signature