Patient Application for 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, recent medical images are necessary.
**It is important to understand that medical imaging of your spine is critical for evaluating whether the Discseel® Procedure is right for you. Dr. Kevin Pauza 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)

Please either drag and drop your medical imaging file or click the browse link below to find the file on your computer

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