Spinal Champion | Patient Success | Improve Your Quality of Life

Spinal Champion®

Patients facing a debilitating back or neck condition can often feel lost, alone, and overwhelmed – but the road to recovery doesn’t have to be a lonely one. Our Spinal Champions program brings together individuals who have achieved improved quality of life through treatment for their neck or back pain to share their own stories of hope and provide encouragement to other patients. Spinal Champions help others find strength, comfort, and peer-to-peer support in a community that understands. We would like to share your story to help give hope to others. In your own words, please answer the following questions:
First and Last Name*
Email*
I consent to possibly having my First Name, Last Initial, and Photo (if provided) to be shared along with my story on social media*
Yes
No
Are you experiencing or have you experienced pain due to your spinal condition?*
If yes, describe the first symptoms you felt at the onset of your pain*
How did these symptoms affect your life?*
How long did you experience these symptoms before you decided to seek treatment?*
What factor forced you to seek treatment?*
What types of treatment did you undergo?*
How has your treatment changed your life? What are you able to do/feel now as a result of your treatment?*
What advice would you give to someone that is suffering from back and/or neck pain?*
Share a Summary of Your Story in 250 words or less
I would like to have my story considered for the 'Get Back To It' Podcast*
Yes
No
We would also love to put a face with a name! Please include a headshot and/or action shot of yourself to include in your Spinal Champion® story.
Max. file size: 2 GB.
Physician/ Provider’s First & Last Name
Practice’s Name
Location (City, State)
I'm interested in being considered for a "Spinal Champion Advocate" volunteer role in which I would be tasked with speaking to other patients about my experience as a Spinal Champion.*
Yes
Maybe
No
Signature*
I, (First & Last Name)
hereby irrevocably authorize the National Spine Health Foundation, its agents and assigns the unrestricted right to produce and use in any format (including the use of any electronic or similar media) including without limitation my voice, my person, likeness and/or medical devices that are used by me internally or externally (all such media representations sometimes referred to as my "likeness"). On behalf of myself, my personal representative and assigns, I transfer, and release any and all claims of ownership of the media representations of my likeness so produced to the National Spine Health Foundation to be used by them and their assigns for their exclusive use without any further consideration, or my prior approval. All such representations of my likeness may appear in any publications of the National Spine Health Foundation (electronic or print), including without limitation, the National Spine Health Foundation website, brochures, advertisements, and/or publications. I understand that all or a portion of any such likenesses may involve the disclosure and use of individually identifiable health information or other medical records; accordingly, this release is to be applicable to all information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you have any questions or concerns, please email efredericks@spinehealth.org

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We’re so excited you’re here! Use this form to tell us your story of healing and recovery so that you can give others hope.

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