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First Name*

Last Name*

Contact Email Address*

Contact Phone Number*

Gender

Age*

Location*

City State / Province / Region Country

How long have you suffered from cervical and/or back pain?*

Have you had any of the following procedures done on your spine?

Spine Fusion
Discectomy
Laser Spine Surgery
Epidural Injections
Other Procedures

When was your last spinal fusion?

How many spinal fusions have you had?

Location of fusions

Neck (cervical)
Back (lumbar)

When was your last Discectomy?

Location of Discectomy

Neck (cervical)
Back (lumbar)

When was your last Laser Spine Surgery?

When was your last Epidural Injection?

Other Procedures

Please Identify your Symptoms:

Low Back Symptoms:

Left Side
Right Side
Both

Leg Symptoms:

Left Leg
Right Leg

Buttock Symptoms:

Left Side
Right Side
Center

Neck Pain:

Left Side
Right Side

Pain In Shoulder Blades:

Left Side
Right Side

Pain In Arm:

Left Arm
Right Arm

Pain In Hand:

Left Hand
Right Hand

Do you currently:

work
I am retired/other

What if any are the physical requirements of your current profession?

What physical activities or sports are you no longer able to do as a result of your condition?

Have you had any of the following medical images taken of your spine of the effect area in the last 24 months?*

MRI
Discogram
CATSCAN
X-RAY
None

**It is important to understand that medical imaging of your spine is critical for evaluating whether the Discseel^® Procedure is right for you. Dr. (Physician Name) may require you to have some medical images taken as part of the process for evaluating your spinal condition and the source of your pain.**

Do you have digital copies of any of these images that you can take/that you can upload?

Yes
No

Please upload your medical images

Drop files here or

Max. file size: 10 MB.

It is difficult for us to evaluate if you are ideal patient for the Discseel^® Procedure and whether it will relieve your spinal pain with out these image. Can you please request digital copies for the medical imaging you had take as indicated above. When you complete this form you will receive an email indicating how you can Upload your medical images to our office once you gotten them.

I understand that by submitting my application for the Discseel^® Procedure it does not constitute the creation of a Doctor Patient Relationship.

I agree to allow my basic none identifiable information to be shared with Discseel^® Technologies the creators of the Discseel® Procedure for statistical research.

By consenting the following information would be shared for the strict purpose of statistical modeling, and building a better understand of the demographic information of individuals seeking the Discseel^® Procedure.

Gender
Age
Date of Application Submission
City and State where applicant resides
How long the applicant has suffered with spine pain
What if any diagnoses the applicant has received
What spinal procedures has the applicant had performed previously on their spine.
Locations of pain and numbness the applicant is experiencing
If the applicant is managing their pain with pain medication
Physical activities the applicant is no longer able to do.

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.

Please indicate from the list how you became aware of the Discseel Procedure*

I have read and agree the Terms & Conditions on this website

INQUIRE TO BE EVALUATED FOR THE DISCSEEL® PROCEDURE

Please Identify your Symptoms:

INQUIRE TO BE EVALUATED FOR THE DISCSEEL^® PROCEDURE