WTS provides MRI & XRay reviews of patient documents for informational purposes. Patients must be seen in the clinic setting and evaluated by a physician to receive a medical diagnosis. If you are under the age of 18 years old, please contact the office directly with a parent or guardian.

Personal Information

	Fields marked with * are required
First Name*
Last Name*
Street Address*
City*
State*
Zip*
Country*

Height*	in.
Weight*	lbs.


Contact Information

Phone Number*
Other Number
Best time to call*
Email*


Other Information

Select Insurance Provider*
Are you being represented by an attorney, or is your injury work related?
Yes	No

Comments:

By submitting your information you agree to receive future emails and correspondence from West Texas Spine. You will have the option of being removed from our mailing lists.

Notice of Limited Use: Any personal information you provide to West Texas Spine by this form will not be used other than to contact you. West Texas Spine will not release your name, street address, telephone numbers or email address for third party use without your consent.

** Please understand that in performing MRI reviews (a) that West Texas Spine is providing only an informational review of documents that you are providing, (b) that West Texas Spine is not providing any form of diagnosis.