PHYSICIAN ORDER FORM - pARK aVENUE mEDICINE & sURGERY - Percutaneous Discectomy 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 a Percutaneous / Endoscopic Discectomy)

Answer Technical and Engineering Questions about Percutaneous / Endoscopic Discectomy.

TREATMENT / Diagnosis:

Percutaneous Discectomy @ L1-L2

Percutaneous Discectomy @ L2-L3

Percutaneous Discectomy @ L3-L4

Percutaneous Discectomy @ L4-L5

Percutaneous Discectomy @ L5-S1

Endoscopic Discectomy @ L1-L2

Endoscopic Discectomy @ L2-L3

Endoscopic Discectomy @ L3-L4

Endoscopic Discectomy @ L4-L5

Endoscopic Discectomy @ L5-S1