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ENQUIRY FORM

Please complete the sections below.

A patient manager will contact you the next working day.

1. Personal details

Date of birth:
Sex:
Height:
cm
Weight:
kg
Contact preference:
How did you find us ?

2. Patient criteria

  • Have you been diagnosed with lumbar/degenerative disc disease?
  • Are you suffering with (chronic) back pain and sciatica?
  • How long have you been suffering?
    Years
    Months
  • Do you have a recent Lumbar MRI scan?
  • Have you been diagnosed with Idiopathic Adolescent Scoliosis?
  • Are you ready for surgery to permanently cure your condition?
  • Are you willing to travel to Montpellier, France? Your stay would typically be, 9 days in total.
  • Are you able to self-fund the treatment? (Typically, £32K+)

3. Your symptoms

  • Main problem
  • Date of first symptoms:
  • Permanent pain since (if applicable):
  • Do you have pain in your arms or legs (sciatica, cruralgia, neuralgia)?
    If yes, please tick the relevant limbs in the diagram below:
    Right Left
  • Is it the main pain?
  • Do you have tingling or numbness in any of your limbs?
  • If yes, since when?
  • Do you have a significant loss of strength in any of your limbs?
  • If yes, since when?
    • Tell us in a few words how your symptoms disable you most:

4. Your treatment history

Indicate any medication you have taken for your pain (if applicable)
Physiotherapy or osteopathy
Discectomy
Brace or lumbar belt
Inpatient stay
Infiltration or thermocoagulation
Rheumatology or specialist medical check-up
List previous spinal surgeries and dates (if applicable)

5. Your diagnostic images

A lumbar MRI scan and a lumbar CT scan, both less than six months old, are required to assess patient suitability for Prodisc-L lumbar disc replacement.
Additionally, a full spinal X-ray less than six months old is required for patients with idiopathic adolescent scoliosis.

Please paste the link to your diagnostic images:
Please paste your login and password:

Spinepro is unable to progress cases without diagnostic images.

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For your information

Your data will remain strictly confidential and secure. Only the CCV Montpellier surgical team and the SpinePro service team will have access.

Medical opinion is governed by Article R.4127-53 of the Public Health Code of France. It is not comparable to a consultation and does not give rise to fees. Fees are only charged if a medical act has been carried out, for which the doctor is responsible, including an act relating to teleconsultation (see E-Diagnosis). Free medical advice is not a "medical act", does not engage the responsibility of its author and is not adapted in the event of an emergency.