Your first step towards improving your condition is to request an appointment with Dr Rosenberg. We offer you the ability to securely register for an appointment with us on line.

Please take a moment to complete and submit the appointment questionnaire form and a scheduling coordinator will contact you within 48 hours. This form is not intended to be used for emergency situations. For emergency situations, dial 911 or go to the nearest Emergency Room.

General Information
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Symptoms / Pain Description


     

     


Diagnostic Tests
Please indicate any diagnostic tests (MRI, X-Rays, EMG, etc.) you have had and the results.
Medications
Please list all of your current medications (include non-prescription drugs, herbal remedies, etc.)
Name (ex: Celebrex) Dosage (ex: 400 mg) Frequency (ex: Twice per day)
Have you seen any of the following Doctors?
Please indicate if any of the following doctors have recommended surgery.
Neurosurgeon
Primary Care Physician
Pain Management Specialist
Physiatrist
Neurologist
Orthopaedist
After submitting this form, you will be taken to a second page where you can provide us with a diagram of the pain/problem you are experiencing.