Patient Contact InformationFirst Name* Last Name* Contact Email* Contact Phone*Are you an existing patient* Yes No Discseel Procedure* I have already completed the Discseel Candidate Application I have NOT already completed the Discseel® Candidate Application Please enter the patient application ID number*Why is this needed? To ensure that your image files are accurately connected to your individual PHI (Protected Health Information) we require this as part the verification process when submitting medical information in separate forms.In order to submit you medical images to be reviewed by Dr. (physician name) for the Discseel® Procedure you must first complete the Discseel® Candidate Application. Click Here to view the application, you will be able to submit your imaging files there as well.Upload Medical Imaging File(s)Please either drag and drop your medical imaging file or click the browse link below to find the file on your computer* Drop files here or Select files Max. file size: 10 MB. * I hereby understand and consent for my medical image(s) to be provided to (practice name), and Discseel® Technologies for evaluation and to be part of imperial medical study information being conducted by Discseel® Technologies. DISCSEEL IMAGING FILE UPLOAD
