Medical Information

Are you the Patient? If no, please tell us

Areas of Difficulty

Select One Neck Mid Back Low Back Knee Other

Has patient had spine surgery?

Yes No

What was done? When was it? Who was the surgeon?

Do you have

Back Pain? Yes No    Leg Numbness? Yes No Neck Pain? Yes No    Leg Weakness? Yes No

Patient's Age

Patient's Sex

Describe patient's problem
The problem started when? How severe is it?
Has patient had a scan?	Yes No         [Required: Please select one]
What did it show?

Will you fax the actual radiology report to our national fax receiving number (310-659-8869)?

Yes No

Name of facility where MRI was done
Phone number of this facility

Has patient seen a surgeon? What was recommended?
What treatment has patient had?
What would you like to ask us?

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More Detailed Information

Insurance Company Name

Type

Select One PPO POS HMO Workers Comp Auto Insurance Other

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