Patient Application for The Discseel® Procedure

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 evaluating your back pain, if you would like to submit recent medical images taken within the last 12 months by uploading them, please select box(es) below. If you do not have medical imaging, please click "None" and proceed to the final step.
**If you don’t have imaging, that’s okay. Your local referring physician or Discseel® providing physician can make arrangements for you to get imaging of your spine.**
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), your Discseel® Doctor requires that you review and consent to the following:
Please indicate from the list how you became aware of the Discseel® Procedure: