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Application to be considered as a candidate for lumbar/cervical disc replacement or stenosis/interspinous posterior stabilization device procedure.

Please fill out the form below and click the 'Submit Application' button. Your request will be e-mailed to RMSAS. If you have not heard from RMSAS within 24 hours, please contact them.

Name
 		E-mail Address
 		Phone Number
Street Address 1
 		Street Address 2
City
 		State
 		Zip
1. What is your age?:
2. Are you pregnant or planning to become pregnant? Yes
No
3. Have you responded to non-operative treatment for a period of 6 months? Yes
No
4. Are you willing to comply with the study plan? Yes
No
5. What procedure are you inquiring about (check all that apply)?



Lumbar Disc Replacement
Cervical Disc Replacement
Lumbar Stenosis or Lumbar Interspinous Posterior Stabilization
Lumbar Nucleus Replacement
6. Do you have one or more of the following conditions as documented by CT, MRI or X-Rays?
(Check all that apply):
Modic Changes
High intensity zones in the Annulus
Loss of disc height
Decreased Hydration
7.  How did you hear about us? Web search engine (i.e.Google)
referral from doctor
referral from patient
referral from other
Story in Paper/Magazine
Advertisement
Television

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