Online Admission Form - Reliant Physical Therapy

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Date	06/18/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Coretta Mikel Hannah
Gender	Female
Date of Birth	12/15/1988
Email	Email hidden; Javascript is required.
Address	524 Will Drive Brandon, Mississippi 39047 Map It
Cell Phone	(601) 896-8034
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Blue Cross Blue Shield
Primary Insurance ID Number	R61301644
Primary Insurance: Patient's Relationship to Insured Party	Spouse
Primary Insurance: Insured Party Name	Corey D Hannah
Primary Insurance: Insured Party DOB	09/25/1985
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	524 Will Drive 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	Corey Hannah
Emergency Contact 1: Phone Number	(601) 594-9857
Emergency Contact 2: Name	Deanna Mikel
Emergency Contact 2: Phone Number	(501) 765-6557
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Knee
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	10/30/2018
Is this injury due to:	Other
Patient Maritial Status	Married
Did you have surgery?	Yes
Date of Surgery	06/16/2026
Surgical Procedure:	ACL & meniscus repair
Rate your overall health:	Excellent
Living Situation	Lives with Family
Do you now or have you ever smoked?	No
Do you have a history of falling?	Yes
How many falls have you had in the past year?	1
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	A Little Bit
Pain
What is the WORST your pain gets on a 0 - 10 Scale?	5/10 - Moderate Pain
Employment
Are you employed?	Yes
Patient Employer	Pilates of Jackson
Occupation	Manager
Patient Employment Status	Other
Duty Level of Work:	Very Light
Are you currently working?	Yes, but on Modified or Light Duty
Patient Employer Address	1491 Canton Mart Road suite 13 Jackson, Mississippi 39211 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Jason Craft
Medical History
Have you had any diagnostic imaging studies for this injury?	MRI
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.	Hydrocodone, ketorolac, journavx,
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Colace
Please list the Other medications you are taking. You may bring in a list if you prefer to do so.	Tirzepatide
How much difficulty do you have in performing this first task?	5/10 - Moderate Difficulty
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;	Coretta Hannah
Signature