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Smith Spinal Care Center

As you read through and answer the questions below, please understand that this is an application to Smith Spinal Care Program. This is NOT a guarantee of acceptance for care. Dr. Smith will assess your case during the consultation and exams to determine if you are a good candidate for care. This DRX 9000 program is only for patients with severe chronic back pain, herniated and bulging disks, spinal stenosis, Sciatica, and spine surgery candidates. Dr. Smith only accepts patients who want and need his help, people who are tired of taking medications, dangerous injections, and want to avoid spine surgeries or those who have had failed back surgeries. Our office only accepts patients willing to follow our recommendations for enough time to stabilize the spine.

PATIENT QUALIFICATION FORM

Please check the pain as being:

How serious is the problem (Check all that apply)