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Bernard Rosenfeld MD - Online Registration

Dr. Rosenfeld and the nursing staff will review your information to determine if you are a candidate for Tubal Reversal surgery. Once it is determined that you are a candidate for the tubal reversal surgery, our staff will arrange your appointments. If you require any assistance in getting started, please call our office at 866-790-0095 and we’d be very happy to assist you.

Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number

Date of Birth *

- Month - Day Year

E-mail *

BMI

Name of hospital where your Tubal Ligation surgery was performed:

Year

City

Last Name at that time