Online Admission Form - Reliant Physical Therapy

Date	08/17/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Carol P Agre
Nickname/Name you liked to be called?	Carol
Gender	Female
Date of Birth	07/18/1952
Email	Email hidden; Javascript is required.
Address	72 Fenceway Drive Brandon, Mississippi 39042 Map It
Cell Phone	(601) 918-6801
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Spouse
Guarantor Name	Edward R Agre
Guarantor Gender	Male
Guarantor Date of Birth	07/03/1957
Guarantor Phone	(601) 918-0274
Guarantor Address	72 Fenceway Drive Brandon, Mississippi 39042 Map It
Insurance Information
Primary Insurance	Medicare
Primary Insurance ID Number	7DA2-EC5-MV25
Primary Insurance: Patient's Relationship to Insured Party	Spouse
Primary Insurance: Insured Address	72 Fenceway Drive Brandon, Mississippi 39042 Map It
Do you have a secondary Insurance.	Yes
Secondary Insurance	G.E.H.A (United Health)
Secondary Insurance ID Number	G44996184
Secondary Insurance: Patient's Relationship to Insured Party	Spouse
Secondary Insurance: Insured Address	72 Fenceway Drive Brandon, Mississippi 39042 Map It
Is this a worker's compensation or other accident claim?	No
Emergency Contacts
Emergency Contact 1: Name	Ed Agre
Emergency Contact 1: Phone Number	(601) 918-0274
Emergency Contact 2: Name	Jeffrey Agre
Emergency Contact 2: Phone Number	(769) 251-6636
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Ankle
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	07/11/2026
Is this injury due to:	Fall
Patient Maritial Status	Married
Briefly describe your symptoms:	Swelling, pain, decreased flexibility(stiffness)
What is your biggest complaint?	See above symptoms
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
Home Layout	One Story Home Shower Stall
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	Moderately
Please check or describe any limitations you have experienced in your Self Care:	Sleeping Chores Caregiving
Pain
Where is the location of your pain?	L ankle
What is the WORST your pain gets on a 0 - 10 Scale?	4/10
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
Pain Description (Please check all that apply)	Burning Dull/Achy Numbness/Tingling Intermittent
What makes your pain worse?	Walking
What makes your pain better?	Ice & elevation
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr Penny Lawin
Medical History
Do you have any of the following medical conditions? (Check all that apply)	I have no significant Medical History High Blood Pressure
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Over the Counter Medications Vitamin/Mineral/Dietary Supplements
Please list any allergies you may have and your bodies response to this allergy.	Versed- N&V
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	ORIF R ankle—2007
What are your goals from physical therapy?	Home exercises to regain normal gait without pain or swelling
Please list a primary functional activity that you have difficulty performing.	Walking
How much difficulty do you have in performing this first task?	4/10
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;	Carol Agre
Signature