Toll-free: (877) 899-7836 Fax: (817) 776-8154
Thank you for your interest in treatment at RMI. In order to begin your evaluation, we need the following information. Once we receive your medical history, a patient care coordinator will contact you to answer general questions and to guide you through the rest of the application process. Most patients will be asked to submit a recent MRI disc and MRI written report in order to complete the evaluation. Once we have received your medical history, MRI disc, and MRI report you will usually be eligle to discuss your case with a doctor. Items marked with (*) are required.
PLEASE NOTE THAT OUT-OF-POCKET FEES START AT $2500. Caution: You must have javascript enabled in your browser to submit this form. Otherwise, you will receive an error when you submit it. Javascript is enabled on most browsers but if you are unsure and need instructions on how to enable javascript you will find them here: http://enable-javascript.com BEFORE YOU COMPLETE THIS FORM: People with conditions like autism should NOT apply here. You should apply through www.cellmedicine.com Thank you.
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Patient Information *First Name: Middle Name: *Last Name: *Birth Date: MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Age: *Gender: SelectMaleFemale *Height: Feet34567 Inches0123456789101112 *Weight: lbs *Address: *City: *State/Province: Not in US or CanadaArmed Forces AmericasArmed Forces Europe: Middle East, & CanadaAlaskaAlabamaArmed Forces PacificArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesYukon Territory *Zip Code: (enter "none" if no zip code) *Country: United StatesUnited KingdomAustraliaCanadaGermanyItalyIndiaMexicoAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAsia/Pacific RegionAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo: The Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropeFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran: Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea: Democratic People's Republic ofKorea: Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia: Federated States ofMoldova: Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania: United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands: BritishVirgin Islands: U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe *Best Phone Number: Home Cell Office Alternate Phone Number: Home Cell Office Fax Number: *Email Address: *Pharmacy Information Emergency Contact Information *First Name: *Last Name: *Relationship: *Phone Number: Street Address: City: State/Province: Not in US or CanadaArmed Forces AmericasArmed Forces Europe: Middle East, & CanadaAlaskaAlabamaArmed Forces PacificArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesYukon Territory Zip Code: Country: United StatesUnited KingdomAustraliaCanadaGermanyItalyIndiaMexicoAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAsia/Pacific RegionAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo: The Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropeFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran: Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea: Democratic People's Republic ofKorea: Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia: Federated States ofMoldova: Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania: United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands: BritishVirgin Islands: U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Medical HIstory and Information *Reason for appointment: Please Describe: *Have you been treated by another physician for this condition? SelectYesNo Physician Name: *Date of Injury or (approximate) date problem began: MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Symptoms (Check ALL that apply): Discomfort Numbness Giving out Popping Stiffness Tingling Paralysis Grinding Soreness Tenderness Instability Swelling *Rate your current pain (0 = No Pain, 10 = Most Severe Pain): Select12345678910 Previous Treatment (Check all that apply): X-Ray MRI Therapy Injection (Type: ) Other: *Drug Allergies: Aspirin Codeine Penicillin Sulfa IV Dye No known drug allergies Other Drug Allergies (Please list): Medications (Please list below):
Have you had the following: *Flu Vaccine: SelectYesNo *Pneumonia Vaccine: SelectYesNo *Do you use tobacco?: SelectYesNo Packs per day: Years: *Do you use illicit drugs? SelectYesNo *Do you use alcohol?: SelectYesNo How much? *6 or more cups of caffeine per day?: SelectYesNo *Occupation: *Dominant Hand: SelectRight HandLeft Hand Do you have a history of (check all that apply): Migraines Hypertension Arthritis Anemia COPD High Cholesterol GERD Blood Disorder Asthma Stroke Hepatitis Cancer Sleep Apnea Seizures Liver Disease Blood Clots AIDS or HIV Depression Diabetes Kidney Disease Heart Disease Anxiety Thyroid Disorder Psychiatric Disorder Other Medical History not listed: *Past Surgical History: SelectYesNo If Yes, please list you past surgeries (From left to right separated by commas): *Have you ever had problems with anesthesia?: SelectYesNo Family History (Please check all that apply):
Adopted? No Pertinent Family Histoy Thank you for taking the time to complete this form. Our medical team will review it within 3 working days and then our staff will contact you. Online Evaluations: For a limited time, as a courtesy to our out-of-state and international patients, we provide a virtual evaluation. Once we have received and reviewed all requested medical information, you may be eligible for a telephone consultation with a staff physician at no charge. Applicants who are not eligible for treatment are not eligible for a free telephone consultation. tation. Office Evaluations: Office evaluations are required for anyone living within the Greater Metropolitan Dallas/Fort Worth area. The fee is $125. Do not click the Submit Form button more than once. You will see a confirmation page once your form has been received. Rev. 8/27/18