Form Upload 1 "(Required)" indicates required fields 1Study type and Image Upload2Patient Details3Clinical Details4Case Details Study Type(Required)Study TypeX-Ray Sectional report (1 region) - $33.00 AUD / £17.25 UK / €20.50 EUR / $23.00 USDX-Ray Full spine report (2+ regions) - $55.00 AUD / £31.00 UK / €36.50 EUR / $41.00 USDMRI Report - $395.00 AUD / £220.00 UK / €250.00 EUR / $295.00 USDMRI Report (per region) - $140.00 AUD / £77.00 UK / €88.00 EUR / $99.00 USDProcedure Type(Required)Procedure TypeCervical SpineThoracic SpineLumbar Spine, Pelvis and HipsFull SpineHipKneeShoulderOtherReport Delivery(Required)Report DeliveryRoutine (24hrs)Medically Urgent (4hrs)Upload your images hereSupported file types include jpg, bmp, tif, zip and dcm. Upload up to 800 images. Max upload 512MB. For a faster upload experience we recommend zipping your images into a zipped folder.Images Drop files here or Select files Accepted file types: jpg, jpeg, bmp, tif, zip, dcm, Max. file size: 660 MB, Max. files: 800. Patient First Name(Required) Patient Last Name(Required) TitleTitleMrMrsMissMsDrPatient DOB(Required) DD slash MM slash YYYY Patient Address I have obtained the above patient's signed consent to x-ray and send the study to PRO for reporting.(Required) Yes No Biomechanical Analysis Inc. scoliosis/sagittal curves/spondylolisthesis/leg length/subluxation/etc Pain Cx Tx Lx Ribs Coccyx SIJ Restricted ROM Cx Tx Lx Degeneration Cx Tx Lx Instability Cx Tx Lx Inflammatory Arthritis Cx Tx Lx SIJ HeadacheHeadacheCervicogenicTensionMigraneClusterExertionalOtherOther DetailsPast surgeriesHx of CancerOther Clinical Details This CaseDate of Study(Required) DD slash MM slash YYYY Practice Location(Required) Referring Practitioner(Required) Report DeliveryReport Delivery
