PHYSICIAN ORDER FORM - pARK aVENUE mEDICINE & sURGERY - MIS (Minimally Invasive Spine) PATIENT EDUCATIONAL MATERIAL REQUEST

Patient Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth: (ex: Month, Day, Year: January, 01, 1990)

MM

DD

YYYY

Please Contact Patient for the Following:

Enroll in Patient Ambassador Program (to connect with another patient who has implant)

Answer Technical and Engineering Questions about Device.

TREATMENT / Diagnosis:

MIS - SACROILIAC JOINT FUSION - Sacroilitis ; Sacroiliac Joint Dysfunction

MIS - MINUTE MAN (Interspinous Fusion) Lumbar Spinal Stenosis (Grade 1 or Grade 2)

MIS - ION (Facet Screw)

REGENERATIVE - VIA DISC (Nucleus Pulposus Allograft) - Degenerative Disc Disease