TMS / Spravato New Patient Enrollment Form

Full Name

First Name Last Name

What type of treatment are you seeking?

Psychiatric Med Management TMS Spravato Therapy Substance Use Disorder Treatment Unsure

Date of birth:

Date

What is your gender?

Contact Number

Email Address

example@example.com

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Primary Insurance:

Member ID:

Are you currently active in treatment at Journey Healthcare?

Yes No

Please Select Current Symptoms

Substance Abuse History - Have you ever considered yourself to have a problem with alcohol or drugs?

Yes No

Please list substance use including substance type and frequency of use.

Do you have any medication allergies or known allergies?

Yes No Not Sure

Please list them.

Do you have any metal objects or implantable devices in or around the head (e.g., cardiac defibrillator/pacemaker, insulin pump).

Yes No Unsure

If yes, please list Medical objects.

Medical Diagnosis?

Yes No

If yes, specify medical diagnosis?

Recent surgeries?

Yes No

If yes, specify recent surgeries:

New Patient Enrollment Form