Transcranial Magnetic Stimulation (TMS)

1
Answer 3 questions, share your insurance information, and let's see if TMS treatment is right for you.
2
What’s the main reason you’re considering TMS therapy?* This field is required.
Depression (including Major Depressive Disorder or Treatment-Resistant Depression)
Anxiety
Something else
3
What payment option would you prefer for TMS treatment? We’ll work with you to find a solution that fits your budget and goals.* This field is required.
I’d like to use my insurance to help keep my out-of-pocket costs low.
I’m open to paying out of pocket or exploring financing options if insurance doesn’t cover treatment.
I don’t have (or prefer not to use) health insurance.
4
Some insurance providers require patients to have tried at least two different oral antidepressants before covering TMS. To help us understand your history, please share your experience with antidepressants.* This field is required.
I've already tried 2 or more different antidepressants ✅
I've tried 1 antidepressant, I am willing to try more ✅
I've tried 1 antidepressant, and I am unwilling to try one more 🚫
I have never used antidepressants 🚫
5
We'd like to help verify your insurance. Please select your provider* This field is required.
Aetna
BlueCross BlueShield
Cigna
Independence
Medicare
UnitedHealthcare
Tricare
Keystone Health Plan East
I don't see my insurance provider
6
Step 1: Upload a picture of the FRONT your insurance card* This field is required.
Drag and drop files here
Select files to upload
Cancelof
7
Step 2: Upload a picture of the BACK your insurance card* This field is required.
Drag and drop files here
Select files to upload
Cancelof

Thank you for sharing with us!

Based on your answers:

TMS could be the right treatment for you!

During TMS treatment our team will assist in getting your treatment delivery just right. This includes a "mapping" which will help us identify the proper treatment location for you, and ensure the treatments are deliverd accordingly each and every time.

Next steps:

We need your Name, Phone, and Email.

Then you can schedule a free call with our team to discuss treatment options, review coverage, pricing, and book your evaluation.

Thank you for sharing with us!

Based on your answers:

TMS could be an option, but it's possible that one of our other services may be better fit!

Next steps:

We need your Name, Phone, Email

Then you can schedule a free call with our team to discuss your treatment options, pricing, and book your evaluation for the service of your choosing.

10
Jotform Responses* This field is required.
11
What is your Name, Phone, and Email:* This field is required.
First Name
Last Name
Please enter your phone
Please enter your email
12
Lead Status* This field is required.
Contacted - awaiting follow up from patient.
Scheduled a consult
Patient Moving Forward - KAP
Patient Moving Forward - IM TRD
Patient Moving Forward - Spravato
Patient Moving Forward - Oral - Healing Hearts
Consult held - patient will get back to us
No showed consult - follow up text sent.
Consult Cancelled
No consult scheduled - sent outreach
New Lead - Staff Needs to Follow up
Lost Lead
Patient Moving Forward with TMS
13
Get Page URL
14
Referrer
15
utm_source
16
utm_medium
17
utm_campaign
18
utm_term
19
utm_content
Should be Empty:

Answer 3 questions, share your insurance information, and let's see if TMS treatment is right for you.

Thank you for sharing with us!

Based on your answers:

TMS could be the right treatment for you!

Next steps:

Thank you for sharing with us!

Based on your answers:

TMS could be an option, but it's possible that one of our other services may be better fit!

Next steps: