International Consultation Form
Individuals located outside of the United States who wish to schedule a video appointment may apply  for consideration via this form.  The purpose of the  video consultation is to review the current the records, talk to the individual and offer an expert opinion.  The doctor patient relationship will not be established, nor treatment provided until the doctor and patient both agree to move forward with an in person consultation and/or treatment session in one of Dr. Rosenblum's office locations.
Email *
First Name *
Last Name
Address *
Country of Origin
Date of Birth
MM
/
DD
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YYYY
Email *
Phone number
Reasons for consultation
Languages Spoken
A copy of your responses will be emailed to the address you provided.
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