International Spinal Cord Regeneration Center

International Spinal Cord Regeneration Center

Evaluation Form

(Print this Form and Fill out the Information)

Please contact us by phone or email first then submit all the following information listed below. We cannot complete an evaluation with any missing documents.

Original X-Ray (at time of the injury)	Current X-Ray (6 Months or Less)
CAT Scat (6 Months or Less)	MRI (6 Months or Less)
Your Medical Chart if available. If Not, a Medical Report such as a discharge summary is sufficient.)

Please submit $200.00 (Cashier Check or Money Order) with the documentation via FEDEX or UPS to:

INBICTO - ORTHOLAB

P.O. Box 451
Bonita, California, 91908

Patient Information

Patient's Name:	Sex:	DOB:
Residence:
City:	State:	Zip:
Home Phone:	Work Phone:	Fax:

Initial Injury

Date of Injury:	Level:	Cause of Injury:
Diagnosis:	Complete:	Incomplete:

Pathology:

Status After Injury:

Procedures Following Injury and Results:

Other Information: