Online Admission Form - Reliant Physical Therapy

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Date	06/22/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Christopher J Moore
Nickname/Name you liked to be called?	Chris
Gender	Male
Date of Birth	07/16/1983
Email	Email hidden; Javascript is required.
Address	102 Britton Cir Flowood, Mississippi 39232 Map It
Home Phone	(601) 260-3573
Cell Phone	(601) 260-3573
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	United HealthCare
Primary Insurance ID Number	976228662
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Christopher J Moore
Primary Insurance: Insured Party DOB	07/16/1983
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	102 Britton Cir Flowood, Mississippi 39232 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	Elizabeth Moore
Emergency Contact 1: Phone Number	(601) 405-5606
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back and hips
What side of the body will we be treating?	Back
Is this injury due to:	Sports Related
Patient Maritial Status	Married
Briefly describe your symptoms:	Sciatica irritation down both legs and stiffness in lower back.
What is your biggest complaint?	Sciatica nerve irritation
How often do you experience your symptoms?	Occasionally (26-50% of the time)
Did you have surgery?	Yes
Date of Surgery	07/15/2019
Surgical Procedure:	L5-s1 fusion
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?	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?	2/10
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	Advarra, inc.
Occupation	Director, Consulting
Patient Employment Status	Full Time
Duty Level of Work:	Very Light
Are you currently working?	Yes - Regular Duty
Patient Employer Address	6100 Merriweather Dr Suite 600 Columbia, Maryland 21044 Map It
Are you disabled or currently on disability?	No
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.	Omeprazole 40mg daily
Please list any allergies you may have and your bodies response to this allergy.	Penicillin
What are your goals from physical therapy?	Stretching/maintenance regimen to strengthen areas, improve flexibility, and relieve discomfort
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
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;	Chris Moore
Signature