APPLY FOR DISCSEEL®
UPLOAD IMAGES FOR DISCSEEL®
Boris Terebuh, MD
The Discseel
®
Procedure
Lumbar Discseel
®
Spine Treatment
Degenerated Disc Treatment Options
The Discseel
®
Procedure
Are You a Discseel
®
Candidate?
Research And References
Patient Success Stories
Hotels & Airports Nearby
Bone Marrow Cells & PRP
Bone Marrow Cell Therapy
Platelet Rich Plasma (PRP) Therapy
How Regenerative Medicine Helps
Preparing For Your Regenerative Procedure
Conditions
Back Pain
Neck Pain
Hip Pain
Knee Pain
Shoulder Pain
Elbow Pain
Hand & Wrist Pain
Foot & Ankle Pain
Treatments
The Discseel
®
Spine Treatment Procedure
Bone Marrow Cell Therapy
Platelet Rich Plasma (PRP) Therapy
Epidural Steroid Injection
Facet Joint Injections & Medial Branch Blocks
Radiofrequency Ablation (RFA) Neurotomy
Sacroiliac Joint Injection
Electrodiagnosis
Patient Resources
Dr. Terebuh explains: videos
Patient Education Videos
Health Blog and News
Patient Forms
Preparing For Your Regenerative Procedure
Preparing For Your Spine Injection
How Image Guided Injections Work
Research And References
Hotels & Airports Nearby
Contact Us
Are You A Discseel® Candidate?
Patient Application for The Discseel
®
Procedure
1
Patient Information
2
Medical History
3
Agreement & Consent
TO CREATE YOUR MEDICAL PROFILE WE REQUIRE SOME BASIC INITIAL PROFILE INFORMATION. PLEASE INPUT ALL THE PROFILE INFORMATION BELOW.
First Name
*
First
Last Name
*
Last
Phone Number
Email
Age
Gender *Optional
Male
Female
Address *Optional
Street Address
City
*
City
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
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Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
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Bulgaria
Burkina Faso
Burundi
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Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
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Congo, Democratic Republic of the
Cook Islands
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Croatia
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Curaçao
Cyprus
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Djibouti
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Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
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Eswatini
Ethiopia
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Finland
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French Guiana
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French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
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Greenland
Grenada
Guadeloupe
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Guinea
Guinea-Bissau
Guyana
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Heard Island and McDonald Islands
Holy See
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
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Liberia
Libya
Liechtenstein
Lithuania
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Macao
Madagascar
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Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
State
*
State / Province / Region
Zip Code *Optional
ZIP Code
I would like to receive information from Dr. Terebuh and the Discseel® Procedure.
“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?
Date of Last MRI
MM slash DD slash YYYY
Hidden
Have you had any of the following procedures done on your spine?
Hidden
Spinal Fusion
When was your last spinal fusion?
How many fusions have you had?
Location?
Hidden
Discectomy
When was your last discectomy?
How many fusions have you had?
Location?
Hidden
Laser Spine Surgery
When was your last laser spine surgery?
How many laser spine surgeries have you had?
Location?
Hidden
Epidural Injections
When was your last epidural injection?
How many epidural injections have you had?
Location?
Hidden
Other Procedures
What was the name of this procedure?
When did you last have this procedure?
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
Arm - Left Side
Arm - Right Side
Hand - Left Side
Hand - Right Side
Buttock - Left Side
Buttock - Center
Buttock - Right Side
Leg - Left Side
Leg - Right Side
Feet - Left Side
Feet - Right Side
Do you have any leg weakness?
Yes
No
Hidden
Do you currently manage your pain with medication?
Yes
No
Hidden
What medications are you currently taking?
Hidden
Do you currently work?
Yes
No
Retired
Other
Hidden
What if any are the physical requirements are needed for your daily life?
Hidden
What physical activities are you no longer able to do as a result of your condition?
As part of the process of submitting your protected health information (PHI), Dr. Boris Terebuh/Regenerative Spine & Joint requires that you review and consent to the following:
*
Select All
*I understand that by submitting my application for the Discseel® Procedure it does not constitute the creation of a Doctor-Patient Relationship.”
*I hereby understand and consent for my medical image (s) to be provided to Dr. Boris Terebuh/Regenerative Spine & Joint. View Privacy Patient Rights Policy in footer.
Please indicate from the list how you became aware of the Discseel® Procedure:
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