Contact Information:
Name   * Email   *
Address City   *
State   * Zip Code
Phone Number   *
Format: 310-123-4567
Best time for us to call you
Medical Information:
Are you the Patient?    If no, please tell us Yes.       If no,  
Areas of Difficulty
Has patient had spine surgery? Yes No
What was done? When was it?
Who was the surgeon?
Do you have Back Pain? Yes No
Leg Pain? Yes No - Left Right Both
Leg Numbness? Yes No
Leg Weakness? Yes No
Patient's Age   |   Patient's Sex years old         Male Female
Please tell us your exact symptoms:
(back pain? leg pain? weakness? numbness? exactly where)
Describe patient's problem
The problem started when?
Have you had chiropractic treatments? Yes No
Has patient seen a surgeon for a present problem? What was recommended?
What tests and treatment has patient had?
Where and when did you have your latest MRI scan?
Are you going to have your MRI scan report faxed to our national receiving fax at 310-659-8869?
(Attn: Dr. David Ditsworth, Chief of Neurosurgery)
Yes No
Describe your usual sport activities before your spine problem:
Are you able to do any sport activity now? Describe:
Do you or did you stress your back in your work? Yes No
Describe your work?
Job Title now (or when you were working)
Where did you hear about us

   If Others,

What would you like to ask us?
If you have a google account, enter your google email address
Other Information:
Insurance Company Name Type

Would you accept responsibility to pay for services not covered by medicare? Yes No

  I Accept *      By checking the "I Accept" box, I agree to the Terms of Use of the Back Institute.

We are the foremost center in the world for Non-Traumatic Spine Procedures.

These procedures are totally non-traumatic in their access for removal of a bulging or herniated discs. These are the most advanced non-traumatic procedures available anywhere, beyond "minimally invasive." We are the world leader in these procedures and our approach is not available at any other facility.

[Consultation by Appointment only]
National Phone Number:
Beverly Hills:
220 S Robertson Blvd,
Beverly Hills,CA 90211
Tel : 310-659-8498
Fax : 310-659-8869
New York City:
135 W. 70th St.
New York, NY 10023

Tel: 212-873-0380
Los Angeles:
920 S Robertson Blvd,
Los Angeles,CA 90035
Tel: 310-551-0690