TMS referral Form

MIU CENTER TMS Referral For Providers
Patient's Name

First NameLast Name
Date of Birth (MM/DD/YYYY)
Phone Number:
Please enter a valid phone number.
Email:
Insurance Company Name and Policy # (If self pay, please state so below):
Please state reason for TMS referral:
Please state how long has patient had these symptoms:
Does the above patient have any metallic plate/device implanted in head, neck, chest or other areas:
Please list any psychiatric symptoms and disorders in the past year (12 months):
Has patient any of the following psychotherapy in the past:

PsychoanalysisCBTOther
Has patient had any other treatment(s) in the past, please explain in detail:

Psychiatric Medications:

Other Medication(s):

Medical History (select all that apply):

MigrainesSeizure disorderCardiovascular DiseaseCerebrovascular DiseaseOther
Referring Provider's Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Signature:

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Send form to appointments@miucentermd.com. Subject title 'TMS Inquiry'
If you have any questions, call 443-275-2068.
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