TMS Consent form

TMS Consent Form

For TMS New Patients
Date of Service:*

MonthDayYear
Date of Visit
Patient Name:*

First NameLast Name
Date of Birth: *

MonthDayYear
Emergency Contact Name: *

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
I understand the Following adverse effects are possible.

1. Up to 10% of Patients undergoing TMS Therapy, experience headaches, face pain, jaw pain, tooth pain or neck pain. you can take over the counter pain reliever. Almost all patients find TMS tolerable.

2. TMS produces a loud clicking noise during stiimulation, which can result in tinnitus or hearing loss especially if ear protection is not used. To prevent risk of hearing disturbances, earplugs will be given at each session.

3. TMS can induce a convulsion even in the absence of brain lesions, epilepsy, or other risk factors for seizures. The overall risk for seizures is less than 1%. TMS does not cause epilepsy.

4. TMS can cause unintended jaw and teeth clenching. You may use a mouth guard during the treatment.

5. I am aware there may be some unexpected complications.

6. I am aware that the risks of exposure to a magnetic field during pregnancy are not fully understood.
Patient Signature:*

Clear
HIPAA Release for Emergency Contact Must Be Completed

After Consent Submitted HIPAA Release will be Filled Out (Will be Redirected after Consent Submission)
Should be Empty:

TMS Consent Form