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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
3
33%
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.
Please check all the boxes to indicate where you are feeling pain?
Low Back -- Left Side
Low Back -- Right Side
Neck -- Left Side
Neck -- Right Side
Hand -- Left Side
Hand -- Right Side
Buttock -- Left Side
Buttock - Center
Buttock -- Right Side
Leg -- Left Side
Leg -- Right Side
Arm -- Left Side
Arm -- Right Side
Feet -- Left Side
Feet -- Right Side
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.
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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
*
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Name
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