July 22, 2015 Free MRI Review Contact InformationName* First Last AddressStreet Address*City*State*Postal Code*Home Phone*Cell PhoneBest Time to CallAnytime9am - 12pm12pm - 3pm3pm - 6pm6pm - 9pmEmail* Enter Email Confirm Email More InformationHow did you hear about us?*Word of mouthOnline - GoogleOnline - BingOnline - YahooNews paperMobile searchRadio commercialTelevision adAlaska Airlines MagazineOtherInsurance*Please Select OnePrivateWorker compensationMedicare, Medicaid, supplementPersonal injury insurance (Motor vehicle incident or other)Self PayCare CreditOtherDo you have another form of payment?CashPayment PlanOther InsuranceNoMEDICARE, 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 specifyWORKERS 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.GenderSelect GenderMaleFemaleYour ConditionYour Condition (Area of Pain) - Select all that apply Lumbar (Lower Back) Thoracic (Mid Back) Cervical (Neck) I have had the symptoms since (the date of onset)I feel numbness/tingling/burning/pins/needles in my (Select all that apply) Neck Back Arms Legs Buttocks Do you feel muscle weakness?YesNoDoes the pain affect your social or family activities?YesNoDo you have decrease of range of motion?YesNoHave you tried Physical Therapy and Chiropractic adjustments?YesNoIs this a work related injury?YesNoHave you had any open spine surgeries?YesNoHave you had any spinal injections?YesNoPlease 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?YesNoWould you like to upload your report, MRI or CT scan images?YesNoClick the SUBMIT button, and you will be taken to a page to upload your MRI or CT scan images.