Arizona Institute for Minimally Invasive Spine Care: Candidate Form

Is Selective Endoscopic Discectomy™ Right For Me?
If you think so, fill in and Submit this form to obtain more information.

Check each appropriate box (as many as apply) if you...

Have leg pain, numbness, tingling made worse by sitting or bending or arching your back
Are not any better after 4 - 6 weeks of conservative treatment including rest and physical therapy
Are not better after epidural blocks
Have an MRI, CT scan, CT myelogram, or discogram showing a disc herniation

Now, please tell us about you and your doctor

Your Email Address

Your Name

Street Address

City, State, Zip

Country

Area Code and Phone

Doctor's Name

Doctor's Email Address

Please describe your condition in as much detail as possible: