Initial Consultation Request
We need the following information from you in order to schedule a complementary consultation with the doctor. The purpose of the initial consultation is to find out whether one may be a good candidate for Spinecor treatment. The consultation is absolutely without charge or obligation.
Please try to fill out below information as accurately as possible. Any information you may share here will not be used for anything other than above description or be shared with anyone.
(The consultation is llimited to 30 per month. Once the number is reached, this form will not work until next month. If this happens, you may wait until next month or call us at (877) 469-6663 and we may schedule you if canellation exists.)
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You must be 18 years old or older in order to request consultation. If you are a minor, please have your legal guardian or one of your parents fill out the form.
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We need your email address as a back up contact. We'll attempt to contact you by email if we cannot reach you by phone.
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This is the primary method which we'll try to reach you.
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From this point on, please enter information regarding whom you are requesting consultation for.
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Please enter the age of the person with scoliosis whom you are requesting consultion for.
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Risser Sign: (0-5) Bone maturity sign
Curve Measurement and Location:
e.g. Thoracic 38, Lumbar 23
Menarche: Date of your first menstruation
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We need your address in order to refer you to the closest provider if treatment is indicated. Referrals are only made at the request of the patient or legal guardian.
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