Philadelphia Surgery Center Contact

INQUIRIES

Our Address

Contact Philadelphia Surgery Center

Call: 484-434-7500

Fax : 310.659.8869

Post Surgery Form #1:
Less than 1 week after procedure

Post Surgery Form #2:
More than 1 week after procedure

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
Do you have	Neck Pain? Yes No Arm Pain? Yes No - Left Right Both Arm Numbness? Yes No Arm 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 stress your back in your work?	Yes No
Describe your work?
Job Title?
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	@gmail.com

Other Information:
Insurance Company Name		Type

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