Please complete all required fields!

(New Patients Only)

Pre-Screening Appointment Form

The Purpose of this form is to provide The Masson Spine Instiute with an understanding of where you are at with your medical issues,
as well as to determine if you are a candidate for the Masson Spine Institute.

Are You Consdering Spinal Surgery?

Yes No Unsure

We only evaluate patients whom are considering Spinal Surgery.

Do you have a history of or currently being treated for any of the following medical conditions?
• Blood Clots • Heart Disease • Lunge Disease • High Blood Pressure • Stroke • Cancer • HIV / Aids • Other Blood Disorders

Yes No

Do you have medical history?

You Responded "NO" to "Are You considering Spinal Surgery?"

Patient candidate status: Not Qualified

Thank you for considering MSI, we are a minimally invasive spine surgery practice and only evaluate people who are in the process of deciding whether they need spine surgery or not.

You do not need to complete this form.
If you have a question you would like to ask please return to the Contact Us form [ Click Here ]

You Responded that you have or had a Medical Issue to "history of or currently being treated...?"

Patient candidate Status: Please Call Us To Discuss Your Situation.

Thank you for considering MSI, we are a minimally invasive outpatient surgical center. Due to the higher risk these medical conditions pose to surgery, we encourage you to give us a call to determine if you are a candidate for the Masson Spine Institute. [ Orlando Office: (407)649-8585 ] | [ Park City Office: (435)649-3317 ]

You do not need to complete this form.
Please call your desired office location
- Orlando Office: (407)649-8585
- Park City Office: (435)649-3317
If you have a question you would like to ask please return to the Contact Us form [ Click Here ]

Has your doctor referred you to the Masson Spine Institute for Cervical or Lumbar spine surgery?

Yes No Which office do you want to go through

What is the problem that you are looking to have evaluated by the Masson Spine Institute?

0/600

Please let us know the reason for evaluation.

Why are you considering Spinal Surgery?

0/600

Please let us know the reason for evaluation.

What are your physical goals after surgery?

0/600

Please let us know your expectations.

Was this due to an injury?

Auto Accident Work Related Injury Other Injury No Injury

Was the issue caused by an injury?

Welcome

Thank you for considering MSI, our goal is to serve you to the best of our ability. To help us provide you with superior services.

Patient Status: Qualified For An Appointment

Please Complete the information below and submit the form.
Our Team will be in contact to coordinate your appointment.

Select an Office Location:

Orlando, Florida Park City, Utah

Which office do you want to go through

Do You Need Travel Concierge Services?

Yes No Which office do you want to go through

What is your age group?

18-28 29-44 45-64 64-74 75+

What age group are you in?

Please let us know your first name.

Please let us know your Last name.

Please let us know your Email address.

Please provide a phone so we can coordinate your consult.