Online Admission Form - Reliant Physical Therapy

Date	08/17/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	802109245 Lincoln Brown
Nickname/Name you liked to be called?	Tyler
Gender	Male
Date of Birth	01/09/1984
Email	Email hidden; Javascript is required.
Address	399 Fannin Landing Circle Brandon, Mississippi 39047 Map It
Home Phone	(601) 906-4962
Cell Phone	(601) 906-4962
Work Phone	(601) 651-3111
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	YAQ 869363485M
Primary Insurance: Patient's Relationship to Insured Party	Spouse
Primary Insurance: Insured Party Name	Jenne Boucher Brown
Primary Insurance: Insured Party DOB	02/07/1986
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	399 Fannin Landing Circle 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	Brandy Gordon
Emergency Contact 1: Phone Number	(601) 955-8817
Emergency Contact 2: Name	Jenne Brown
Emergency Contact 2: Phone Number	(303) 918-1771
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	All over for strength
What side of the body will we be treating?	Other
Date of Injury or when your pain began.	07/15/2026
Is this injury due to:	Cancer
Patient Maritial Status	Married
Briefly describe your symptoms:	Very weak from cancer treatment and pain meds. Need to work on getting strength back.
What is your biggest complaint?	Legs weak
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Fair
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	Quite a Bit
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?	4/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	4/10
What makes your pain better?	Taking pain meds
Employment
Are you employed?	Yes
Patient Employer	Self
Occupation	Insurance agent
Patient Employment Status	Full Time
Are you currently working?	No
Patient Employer Address	Mississippi Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr Marc Matrana
Medical History
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;	Tyler Brown
Signature