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 *

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Referring Provider Phone Number*
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Referring Provider Email
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Patient Name*

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Phone Number*
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Email
Preferred Contact

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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
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Spravato ® (esketamine) referral