1

Name* This field is required.Please type your name

First Name

Last Name

2

Please Enter Your Contact Information* This field is required.

Please enter your email

Please enter your phone

What's the best way for us to contact you?

3

Date of Birth * This field is required.

Date

4

Let's start with the basics, and then we'll get you scheduled with someone from our team to chat more. Do you have a history of depression that's been resistant to treatment?* This field is required.

YESNO

6

Are you currently a patient with our practice? * This field is required.

YESNO

7

Please provide a brief summary of your treatment history, including your symptoms, any medications or treatments that have not worked for your depression, and your current medications / treatments. Feel free to be as detailed as you’re comfortable with.* This field is required.

8

TMS is covered under most insurance plans and Medicare. Would you like to upload a photo of your insurance cards so we can verify your coverage for you?

Yes, I'll upload a photo of my insurance card

I don't have it right now, but I'll make sure I do the next time we chat

9

Insurance Info

10

Please upload a copy of your insurance card * This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

11

Please take a photo of the front of your insurance card* This field is required.

12

Please take a photo of the back of your insurance card.* This field is required.

13

As a part of our information gathering, we'd like to get a bit more clarity about your symptoms. The following questionnaire consists of 9 statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling for the past 2 weeks

16

How often have you been bothered by any of the following problems?* This field is required.

Not At All

Several Days

More than half the days

Nearly Everyday

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not At All

Several Days

More than half the days

Nearly Everyday

17

How often have you been bothered by any of the following problems?* This field is required.

Not At All

Several Days

More than half the days

Nearly Everyday

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual.

Not At All

Several Days

More than half the days

Nearly Everyday

18

How often have you been bothered by any of the following problems?* This field is required.

Not At All

Several Days

More than half the days

Nearly Everyday

9. Thoughts that you would be better off dead or of hurting yourself in some way

Not At All

Several Days

More than half the days

Nearly Everyday

19

If you checked off any problems, how often have these problems made it difficult for you to do your work, take care of things at home, or get along with other people?* This field is required.

Not At All

Several Days

More than half the days

Nearly Everyday

Check One

Not At All

Several Days

More than half the days

Nearly Everyday

20

Is there anything else you'd like us to know?

21

Please provide your name, phone number, and email address. Next, you can choose the day and time you'd like our team to call you.* This field is required.

What's your name

Please enter your phone

Please enter your email

22

TMS Interest Form

Thank you!

The next step is to select the day and time you would like to speak to our team.

Our team will call you on the day you choose to discuss the treatment process and answer any questions you may have