Free MRI Review Where is your worst pain?Please SelectLower Back and/or Leg Pain (Lumbar Spine)Neck and/or Arm Pain (Cervical Spine)Mid-Back and/or Ribs Pain (Thoracic Spine) Does the pain radiate from your lower back to your legs?Please SelectYesNo Do you experience numbness, weakness, or tingling in your legs or feet?Please SelectYesNo Does the pain radiate from your neck to your arms?Please SelectYesNo Do you experience numbness, weakness, or tingling in your arms or hands?Please SelectYesNo How bad does your pain get on a scale of 1-10 (10 being the worst)?Please Select12345678910 What previous treatments have you undergone?SurgeryTherapyInjectionsPain MedicationsNone What is your First name? What is your Last name? Enter your E-mail Enter your Zip Code Enter your Phone Number What year were you born?Please Select202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930 How did you hear about us?Please SelectOur Facebook PageInstagramYouTubeSearch Engine (Google, Bing, etc.)Recommended by Family or FriendNone Insurance NamePlease SelectAetnaAnthemBeech StreetBlue Cross Blue ShieldCignaCoventryEmpireHumanaKaiser PermanenteMedicaidMedicareMedicare HybridMultiplanTricareUnited Health CareAuto AccidentWorker's CompensationOtherNone Please Specify Are you using a mobile device (phone, tablet, etc.)?YesNo Are you able to travel to Schell Spinal in Michigan for treatment, if needed?Please SelectYesNo Have you had an MRI within the last 18 months?Please SelectYesNo Do you have your MRI images and report?Please SelectYesNo We cannot complete your MRI Review without a recent MRI. If you have not had an MRI within the last 18 months, please request one from your primary care or pain management provider. Once you have completed the MRI scan, please request that your images be put on a CD or flash drive and given to you. Return to this form, and either upload your MRI images and report or mail them to our office. How will you send us your MRI images and report?Please SelectThe MailUpload Attn: Jennifer WestSchell Spinal3160 Cabaret Tr. SouthSaginaw MI 48603 Please upload your DICOM folder as a ZIP file Please include any other information or history you would like the Schell Spinal team to know about.
