Free MRI Review for Lumbar Fusion Candidacy

Please note CemLIF surgery is currently only performed in Naples, Florida and is only partially covered by insurance. For more details see the FAQ page.

Has a surgeon recommended you undergo lumbar surgery?

Has a surgeon recommended you undergo lumbar surgery?*

Yes - I'd like to see if I'm a CemLIF candidate

No - I have not had surgery recommended yet

Who was the surgeon that recommended you undergo lumbar surgery?

Provider Name

Provider City, State, and Country

Recommended Surgery

Have you had previous neck or back surgery?

Have you had previous neck or back surgery?*

Yes

Surgery Details*

Surgery name, approximate date, and name of surgeon

Do you have a recent MRI or CT scan of your lumbar spine?

Do you have a recent MRI or CT scan?*

Yes

What type of scan and where was it performed?*

How would you like to send us your images?*

I'll upload them online now

Please call my imaging facility to request a CD

I'll mail you a CD myself

I can share portal/PACS access

Great — you can send the files from your MRI, CT, or X-ray disc through our secure upload tool. It opens in a new tab so you will not lose this form, and the same link appears again once you submit.

Open the upload tool

Imaging Facility Name*

Imaging Facility Phone Number*

Please mail your CD along with your name and date of birth to:

Attn: MRI Review
6101 Pine Ridge Road
Naples, FL 34119

Which patient portal or imaging system holds your images?*

For example: MyChart, or the name of the hospital or imaging center. Please do not enter passwords — our team will contact you to arrange secure access.

Your Information

First Name*

Last Name*

Phone*

Email*

Address

City, State, Country

Your Date of Birth*

MM slash DD slash YYYY

Insurance Information

Insurance Company

Member ID

Additional Info

Consent*

I have read the Privacy Policy and agree that CemLIF may contact me by phone, text message, or email about my request. I understand I am voluntarily submitting health information so the practice can review it.*

Your information is used only to respond to your request. You may withdraw this consent at any time by contacting us.

Free MRI Review

4 Easy Ways to Get Us Your Images

Upload Online

We Call Your Facility

Mail Us a CD

Share Portal Access

Please note CemLIF surgery is currently only performed in Naples, Florida and is only partially covered by insurance. For more details see the FAQ page.

Your Information

Insurance Information

Additional Info