Step 1 of 4 25% Where is your worst pain?(Required)Please SelectLower Back Pain (Lumbar Spine) and/or LegNeck Pain (Cervical Spine) and/or ArmMid Back Pain (Thoracic Spine) and/or RibsDoes the pain radiate from your lower back to your leg(s)?(Required)Please SelectYesNoIn which leg do you feel pain?(Required)Please SelectLeftRightBothIn which leg do you feel more pain?(Required)Please SelectLeftRightDo you experience numbness, weakness, or tingling in your leg/foot?(Required)Please SelectYesNoDoes the pain radiate from your neck to your arms?(Required)Please SelectYesNoIn which arm do you feel pain?(Required)Please SelectLeftRightBothIn which arm do you feel more pain?(Required)Please SelectLeftRightDo you experience numbness, weakness, or tingling in your arm/hand?(Required)Please SelectYesNoHow bad does your pain get on a scale of 1-10? (10 = worst pain)(Required)Please Select12345678910What treatments have you had previously?(Required) Surgery Therapy Pain Medications Injections None Are you using a mobile device?(Required) Yes No This can be a cell phone, tablet, etc.What is your First Name?(Required) What is your Last Name?(Required) Enter your Email(Required) Enter your Zip Code(Required) Enter your Phone Number (If you are outside of U.S. please include country code)(Required)What year were you born?(Required)Please Select2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How did you hear about us?(Required)Please SelectOur Facebook PageFacebook Support GroupTwitterLinkedinInstagramYouTubeGoogle, Bing, or YahooRecommendation by Friend or FamilyInsurance Name(Required)Please SelectAetnaAnthemBeech StreetBlue Cross Blue ShieldCignaCoventryEmpireHumanaKaiser PermanenteMedicaidMedicare HybridMedicareMultiplanTricareUnited Health CareAuto AccidentWork CompNoneOther Are you able to travel to Deuk Spine Institute in Florida for treatment, if needed?(Required)Please SelectYesNoHave you had an MRI within the last 18 months?(Required)Please SelectYesNoWe 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. Do you have your MRI images and report?(Required)Please SelectYesNoTo complete your MRI Review, we will need both of the following: Written report/Radiologist reading MRI images in DICOM format How will you send us your MRI images and report?(Required)Please SelectFile UploadMail (USPS, FedEx, UPS)Portal AccessIf your imaging center allows provider access to your images, please assign permission to MRIreview@deukspine.com and paste the access link below. PLEASE NOTE: If we are unable to access your online portal due to encryption or security conflicts on our browsers, you will need to return to this form to upload your images in DICOM format or mail your CD/USB to: Millennium Medical Management Attn: MRI Review 7955 Spyglass Hill Rd Melbourne, FL 32940 ***Deuk Spine Institute is not responsible for returning MRI discs or images. If you wish to retain the originals, please make an additional copy or include a stamped, self-addressed return envelope with your images*** Please copy and paste your online portal URL here:(Required) Portal Username(Required) Portal Password(Required) If there is no password required, please enter "N/A".I give permission for Deuk Spine Institute to use the credentials through the link above to view and/or download files if necessary.(Required) Yes No Please mail (NOT Email) your MRI CD/USB and report to: Millennium Medical Management Send to: Attn: MRI Review 7955 Spyglass Hill Rd Melbourne, FL 32940 ***Deuk Spine Institute is not responsible for returning MRI discs or images. If you wish to retain the originals, please make an additional copy or include a stamped, self-addressed return envelope with your images***Your images must be in DICOM format! If the images on the disc/USB are not in DICOM format (.dcm, .dic) we will not be able to view them. If your images are in a different format, please convert them to DICOM before uploading. This online file converter will convert your files to DICOM format. www.onlineconverter.com/jpg-to-dicom ***This is an external site, not affiliated with Deuk Spine Institute. Please exercise caution.*** Upload your MRI REPORT(Required)This is the radiologist read of your images, usually 1-2 pages long. MRI Report Sample × Drop files here or Select files Accepted file types: pdf, doc, docx, html, wpd, txt, exe, jpg, png, tif, Max. file size: 100 GB. Upload your MRI images in DICOM format(Required)These are found on the disk or flash drive in your possession. We need all the DICOM files on the disk, there may be hundreds of them. DICOM imaging is required for an MRI review to be done. Please make sure to allow all files to upload before moving to the next page. Drop files here or Select files Accepted file types: dcm, dic, Max. file size: 200 GB. Need Help? Watch This Video Please include any other information or history you would like our team to know about.ReCaptchaPhoneThis field is for validation purposes and should be left unchanged.