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Patient Application for The Discseel® Procedure

1

Patient
Information

2

Medical
History

3

Medical
Images

4

Research
and Consent

To create your medical profile we require some basic initial profile information. Please input all the profile information below.
To help better understand your symptoms and evaluate whether the Discseel® Procedure is right for you, please provide answers on your medical history below.

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

Please check all the boxes to indicate where you are feeling pain

Do you currently manage your pain with medication?

Do you currently

As part of the process of evaluating if the Discseel® Procedure is right for you, often we find medical imaging to be helpful
**It is important to understand that medical imaging of your spine is critical for evaluating whether the Discseel® Procedure is right for you. Southwest Spine and Sports 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.**

Upload Medical Imaging Files(s)

As part of the process of submitting your protected health information (PHI), Southwest Spine and Sports requires that you review and consent to the following:
Please indicate from the list how you became aware of the Discseel® Procedure: