Full Page Form Only - MRI Review Upload

Step 1 of 4

Where is your worst pain?(Required)

Does the pain radiate from your lower back to your leg(s)?(Required)

In which leg do you feel pain?(Required)

In which leg do you feel more pain?(Required)

Do you experience numbness, weakness, or tingling in your leg/foot?(Required)

Does the pain radiate from your neck to your arms?(Required)

In which arm do you feel pain?(Required)

In which arm do you feel more pain?(Required)

Do you experience numbness, weakness, or tingling in your arm/hand?(Required)

How bad does your pain get on a scale of 1-10? (10 = worst pain)(Required)

What treatments have you had previously?(Required)

Surgery

Therapy

Pain Medications

Injections

None

Are you able to travel to Deuk Spine Institute in Florida for treatment, if needed?(Required)

Have you had an MRI within the last 18 months?(Required)

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.

Do you have your MRI images and report?(Required)

To 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)

If 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

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

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

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

Accepted file types: dcm, dic, Max. file size: 200 GB.

Please mail (NOT Email) your MRI CD/USB and report to:

Your images must be in DICOM format!

Need Help? Watch This Video