Online Admission Form - Reliant Physical Therapy

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Date	06/23/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Renada Renee Dixon
Nickname/Name you liked to be called?	Nea
Gender	Female
Date of Birth	03/17/1981
Email	Email hidden; Javascript is required.
Address	5590 Henderson Rd Pearl Ms Pearl, Mississippi 39208 Map It
Home Phone	(769) 366-1847
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Magnolia Health - MS CAN/MS CHIP
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Renada Dixon
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	5590 Henderson Rd Pearl Ms 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	William Horton
Emergency Contact 1: Phone Number	(601) 559-1104
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back knee shoulder
What side of the body will we be treating?	Both
Is this injury due to:	Other
Patient Maritial Status	Single Divorced
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Good
Home Layout	One Story Home Combo Tub/Shower
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	Extremely
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing Kneeling
Pain
Where is the location of your pain?	Back
What is the WORST your pain gets on a 0 - 10 Scale?	10/10 - Severe Pain
What is the BEST your pain gets on a 0 - 10 Scale?	9/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	10/10 - Severe Pain
Pain Description (Please check all that apply)	Burning Sharp Dull/Achy Throbbing Shooting Numbness/Tingling Constant Intermittent Worse in AM Worse in PM Worse at night while sleeping
Employment
Are you employed?	Yes
Patient Employment Status	Part Time
Are you currently working?	Yes, but on Modified or Light Duty
Patient Employer Address	Mississippi Map It
Are you disabled or currently on disability?	No
Medical History
Have you had any recent or unexplained weight loss?	No
How much difficulty do you have in performing this first task?	9/10
How much difficulty do you have in performing this second task?	9/10
How much difficulty do you have in performing this third task?	8/10
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?	Other
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;	Renada Dixon
Signature