Discseel® Candidate

Patient Application for The Discseel® Procedure

1

Patient
Information

2

Medical
History

3

Research
and Consent

To create your medical profile we require some basic initial profile information. Please input all the profile information below.

Gender *Optional

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 submitting your protected health information (PHI), Regenerative Spine and Joint Center requires that you review and consent to the following:
Please indicate from the list how you became aware of the Discseel® Procedure: