Online Admission Form - Reliant Physical Therapy

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Date	05/29/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Sawyer Drake Smith
Nickname/Name you liked to be called?	Drake
Gender	Male
Date of Birth	05/28/2009
Email	Email hidden; Javascript is required.
Address	236 Gatewood Drive Pearl, Mississippi 39208 Map It
Cell Phone	(601) 835-8825
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Guardian
Guarantor Name	Afton Elizabeth Linton
Guarantor Gender	Female
Guarantor Date of Birth	02/28/1982
Guarantor Phone	(601) 835-8825
Guarantor Address	236 Gatewood Drive Pearl, Mississippi 39208 Map It
Insurance Information
Primary Insurance	Magnolia Health - MS CAN/MS CHIP
Primary Insurance ID Number	853472735
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Sawyer Drake Smith
Primary Insurance: Insured Party DOB	05/28/2026
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(601) 888-0842
Primary Insurance: Insured Address	236 Gatewood Drive Pearl, Mississippi 39208 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	Afton Linton
Emergency Contact 1: Phone Number	(601) 835-8825
Emergency Contact 2: Name	Brad Smith
Emergency Contact 2: Phone Number	(601) 918-1881
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Right arm
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	04/14/2026
Is this injury due to:	Sports Related
Patient Maritial Status	Single
How did your symptoms start?	Broke my arm
What is your biggest complaint?	Numbness/tingling in fingers
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	Yes
Date of Surgery	04/15/2026
Rate your overall health:	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	A Little Bit
Please check or describe any limitations you have experienced in your Self Care:	Chores
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use Fine Hand Use
Pain
Where is the location of your pain?	Fingers
What is the WORST your pain gets on a 0 - 10 Scale?	5/10 - Moderate Pain
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?	1/10
Pain Description (Please check all that apply)	Numbness/Tingling
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Erin Bass
Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
What are your goals from physical therapy?	Help tinglin numbness and use of arm more
Please list a primary functional activity that you have difficulty performing.	Basketball
How much difficulty do you have in performing this first task?	6/10
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;	Afton Linton
Signature