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Apply For Discseel
®
615.953.9512
OUR TEAM
REGENERATIVE MEDICINE
The Discseel
®
Procedure
Platelet Rich Plasma Therapy (PRP)
Stem Cell Therapy
Prolotherapy
MED SPA
THE DISCSEEL
®
PROCEDURE
Live Pain Free with The Discseel
®
Procedure
Degenerated Disc Treatment Options
The Discseel
®
Procedure
Are you a Discseel
®
Candidate?
Research & References
Patient Success Stories
Discseel® Procedure FAQs
CONDITIONS
Back Pain
Neck Pain
Joint and Limb Pain
PATIENT EDUCATION
How Regenerative Medicine can Help
Discseel
®
Research
Health Blog and News
Patient Forms
CONTACT
OUR TEAM
REGENERATIVE MEDICINE
The Discseel
®
Procedure
Platelet Rich Plasma Therapy (PRP)
Stem Cell Therapy
Prolotherapy
MED SPA
THE DISCSEEL
®
PROCEDURE
Live Pain Free with The Discseel
®
Procedure
Degenerated Disc Treatment Options
The Discseel
®
Procedure
Are you a Discseel
®
Candidate?
Research & References
Patient Success Stories
Discseel® Procedure FAQs
CONDITIONS
Back Pain
Neck Pain
Joint and Limb Pain
PATIENT EDUCATION
How Regenerative Medicine can Help
Discseel
®
Research
Health Blog and News
Patient Forms
CONTACT
Menu
OUR TEAM
REGENERATIVE MEDICINE
The Discseel
®
Procedure
Platelet Rich Plasma Therapy (PRP)
Stem Cell Therapy
Prolotherapy
MED SPA
THE DISCSEEL
®
PROCEDURE
Live Pain Free with The Discseel
®
Procedure
Degenerated Disc Treatment Options
The Discseel
®
Procedure
Are you a Discseel
®
Candidate?
Research & References
Patient Success Stories
Discseel® Procedure FAQs
CONDITIONS
Back Pain
Neck Pain
Joint and Limb Pain
PATIENT EDUCATION
How Regenerative Medicine can Help
Discseel
®
Research
Health Blog and News
Patient Forms
CONTACT
Are You A Discseel® Candidate?
Home
Discseel
Are you a Discseel® Candidate?
Patient Application for The Discseel® Procedure
Step
1
of
4
25%
First Name
*
Last Name
*
Phone
*
Phone Number
Email
Your E-mail
Age
Your Age
Gender
Male
Female
Street Address
City
State
Zip
Consent
I would like to receive information from Nashville Spine Institute and the Discseel® Procedure by mail
Medical History
To help better understand your symptoms and evaluate whether the Discseel® Procedure is right for you, please provide answers on your medical history below.
How long have you been suffering from cervical and/or back pain?*
Have you been diagnosed with any other conditions?
Have you had any of the following procedures done on your spine?
Spinal Fusion
Descectonomy
Laser Spine Surgery
Epidural Injections
Other Procedures
Please check all the boxes to indicate where you are feeling pain?
Low Back -- Left Side
Neck -- Right Side
Hand -- Left Side
Buttock - Center
Leg -- Right Side
Low Back -- Right Side
Arm -- Left Side
Hand -- Right Side
Buttock -- Right Side
Feet -- Left Side
Neck -- Left Side
Arm -- Right Side
Buttock -- Left Side
Leg -- Left Side
Feet -- Right Side
Do you currently manage your pain with medication?
Yes
No
Do you currently
Work
Are You Retired/Other
Medical Images
As part of the process of evaluation if the Discseel® Procedure is right for you, often we find medical imagining to be helpful.
Have you had any of the following medical images taken of your spine of the affected area in the last 12 months?
MRI
Discogram
CAT-scan
X-Ray
None
Research and Consent
As part of the process of submitting your protected health information (PHI), Nashville Spine Institute requires that you review and consent to the following:
Consent regarding Doctor Patient Relationships
*
I understand that by submitting my application for the Discseel® Procedure it does not constitute the creation of a Doctor Patient Relationships.
Consent to use data for statistical research
*
I agree to allow my basic none identifiable information to be shared with Discseel® Technologies the creators of the Discseel® Procedure for statistical research.
Consent for medical image(s) to be used for evaluation
*
I hereby understand and consent for my medical image(s) to be provided to Nashville Spine Institute and Discseel® Technologies for evaluation and to be part of imperial medical study information being conducted by Discseel® Technologies.
Consent to be contacted
*
I would like to receive regular communication from Nashville Spine Institute and Discseel® Technologies on the Discseel® Procedure and overall spine health.
Consent for payment
*
I understand this is a self-pay procedure.
Please indicate how you became aware of the Discseel® Procedure
Search Engine
Online Ads
Physician Referral
Discseel® Patient Referral
Social Media
Television
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Comments
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You are requesting a patient package
To receive your patient package, please let us know what your name and email address is by filling out the fields below.
Name
*
First
Last
Email
*
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
