Transcranial Magnetic Stimulation (TMS) referral

Transcranial Magnetic Stimulation (TMS) referral
Transcranial Magnetic Stimulation (TMS) is FDA approved for treatment resistant MDD. Please call 629-255-1652 if you have any questions
Referring Provider Name*

First NameLast Name
Referring Provider Phone Number*
Please enter a valid phone number.
Referring Provider Email
example@example.com
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.
Patient Email
Preferred Contact

PhoneEmailText
Insurance (if known)

TricareAetnaCignaAnthem Blue CrossCignaBlue ShieldMedicareRegal Medical GroupVA Community Care (will need an eval from the VA in order to get a referral0United Healthcare/OptumMagellanOther
Brief Clinical History
Current Psychotropic Meds (if none, put none)*
Previous medication trials (if known, with dates)
Current and Previous therapy (type and date, if known)
No active seizuresNo history of epilepsyNo current substance abuseNo metal implants or devices in or near the head or neck that are magnetic-sensitive or conductive. ( includes cochlear implants, pacemakers, stents, aneurysm clips, and bullet fragments)No Bipolar disorder
Please upload any applicable clinical notes and/or release of information, if available

Cancelof
Should be Empty: