Free MRI Review | Canada, Vancouver, and BC Patients

Contact Information

Name*

Address

Street Address*

City*

Province*

Postal Code*

Home Phone

Cell Phone*

Best Time to Call

Email*

Enter Email Confirm Email

More Information

How did you hear about us?*

Insurance*

Do you have another form of payment?

Cash
Payment Plan
Other Insurance
No

MEDICARE, MEDICARE + SUPPLEMENTAL - Sorry, you are not a candidate for services at our clinic, because government programs do not currently pay for laser spine surgery.

If Other, please specify

WORKERS COMPENSATION - Spine Institute Northwest works with private workers compensation. We recommend that you obtain pre-approval of surgery prior to entering our treatment programs.

PERSONAL INJURY INSURANCE - Spine Institute Northwest works with many type of insurers. We accept assignment of benefits and insurance liens. Our patient advocates and reimbursement specialists are always ready to assist you for best results.

For your convenience, your Spine care could be expedited by extension of credit through Care Credit upon completion of qualifying application.

SELF PAY - Spine Institute Northwest has helped many individuals on a self pay basis. We offer flexible monthly payments and have affordable financing options to fit most people’s budgets. We will work with you to make our services as affordable as possible.

Gender

Your Condition

Your Condition (Area of Pain) - Select all that apply

Lumbar (Lower Back)
Thoracic (Mid Back)
Cervical (Neck)

How much pain is there? (Scale 1 -10)*

I have had the symptoms since (the date of onset)

I feel numbness/tingling/burning/pins/needles in my (Select all that apply)

Do you feel muscle weakness?

Yes
No

Does the pain affect your social or family activities?

Yes
No

Do you have decrease of range of motion?

Yes
No

Have you tried Physical Therapy and Chiropractic adjustments?

Yes
No

Is this a work related injury?

Yes
No

Have you had any open spine surgeries?

Yes
No

Have you had any spinal injections?

Yes
No

Please provide all related information in the space provided below:

Do you currently have your report, or a copy of your MRI or CT scan images?

Yes
No

Would you like to upload your report, MRI or CT scan images?

Yes
No

Click the SUBMIT button, and you will be taken to a page to upload your MRI or CT scan images.