Patient Ketamine & TMS Referral Form

What's This Referral For?

Physician / Provider Name:

Physician / Provider Specialty:

Referral Date:

MonthDayYear

Physician / Provider Address:

Address

Indirizzo Riga 2

City

Zip Code

Physician/Provider Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Physician/Provider Email:

example@example.com

Name:

First NameLast Name

Date of Birth:

MonthDayYear

Patient Address:

Address

Indirizzo Riga 2

City

Post Code

Home/Cell Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Email:

example@example.com

Which treatment do you feel is most appropriate for this patient?

Other

Do you believe this patient may have an active substance use disorder?

Is this or has this patient received therapy in the past?

Patient's Relevant Medical History:

Patient's Previous Psychiatric Medication(s):

Patient's Current Psychiatric Medication(s):

Please select any of the following potential contraindications:

Other Information

1. Patient will be contacted by our office for screening and scheduling. They will receive pre-procedure instructions. A $250 consultation fee may be collected at that time to cover the initial consultation. If they are approved for ketamine therapy or TMS and proceed with the first treatment, the $250 dollars will be applied towards the series of 6 treatments, $3250.

2. Patient will receive treatments of ketamine or TMS over a 2-week period. Dosing of ketamine starts around 0.5 mg/kg and will be adjusted on a per-patient basis.

3. We will check their mood throughout their weeks of treatment, and after the eighth week, we will determine whether ketamine or TMS has been effective for their treatment-resistant depression. For the responders, maintenance infusions may be scheduled. On average, maintenance infusions last 9 to 16 weeks.

Please read the following and sign below:

This patient and I would like to initiate ketamine therapy as an adjunct to the management of the above illness.

I acknowledge that additional information about this therapeutic option is available by discussing treatment options in more detail if required.

I will follow up with this patient during and after the treatment course at TMS + Mind MD, or refer him/her to a licensed medical professional for follow-up.

Relevant Medical Reports

Referring Physician / Provider Signature

Patient Ketamine & TMS Referral Form

Your Practice Details:

Patient Details:

Treatment Protocol: