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
Research And References
Health Blog and News
Preparing For Your Regenerative Procedure
Preparing For Your Spine Injection
How Image Guided Injections Work
Patient Education Videos
Patient Forms
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
State
*
State / Province / Region
Zip Code *Optional
ZIP Code
I would like to receive information from Dr. Terebuh and the Discseel® Procedure by mail.
“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
When was your last spinal fusion?
How many fusions have you had?
Location?
Discectomy
When was your last discectomy?
How many fusions have you had?
Location?
Laser Spine Surgery
When was your last laser spine surgery?
How many laser spine surgeries have you had?
Location?
Epidural Injections
When was your last epidural injection?
How many epidural injections have you had?
Location?
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 currently manage your pain with medication?
Yes
No
What medications are you currently taking?
Do you currently work?
Yes
No
Retired
Other
What if any are the physical requirements are needed for your daily life?
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), (Insert Business Name) 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.” (checkbox)
“*I agree to allow my basic non-identifiable information to be shared with Discseel® Technologies the creators of the Discseel® Procedure for statistical research.”
“*I hereby understand and consent for my medical image(s) to be provided to (Insert Business Name) and Discseel® Technologies for evaluation and to be part of imperial medical study information being conducted by Discseel® Technologies. View Privacy Patient Rights Policy.”
“I would like to receive regular communication from (Insert Business Name) and Discseel® Technologies on the Discseel® Procedure and overall spine health.”
Please indicate from the list how you became aware of the Discseel® Procedure:
Search Engine
Online Ads
Physician Referral
Discseel® Patient referral
Social Media
Television
Other
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