TMS referral

Spravato ® (esketamine) referral
Spravato ® (esketamine) is FDA approved for treatment resistant depression and the depressive symptoms of MDD with suicidal ideations. Pt needs to be on antidepressant while starting treatment. Please call 629-255-1652 if you have any questions
Referring Provider *

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 Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
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 or unknown)*
Previous medication trials (if known, with dates)
Current and Previous therapy (type and date, if known)*
Please confirm absence of contraindictions (if in doubt please refer and we can evaluate further)*

No aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformationNo intercerebral hemorrhage (stroke)Not pregnant or breastfeedingNo current substance abuse
Please upload any applicable clinical notes and/or release of information, if available

Cancelof
Should be Empty:

Spravato ® (esketamine) referral