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To request an initial consultation for TMS, please complete the information below:
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Do you have insurance?
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Option 3
If yes, which company?
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Have you previously had TMS treatment?
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Yes, I have done TMS previously
No, this would be my first TMS treatment
NAME
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Date of Birth
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Phone number
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Email
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How did you find our practice?
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What symptoms/diagnosis are you seeking treatment for?
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Please list all current psychiatric medications and doses
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Have you had a recent psychiatric hospitalization?
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Yes
No
Option 3
Do you have a history of substance abuse?
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No
Option 3
Please check if you have a history of the following...
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Epilepsy or ever had a convulsion or seizure
Fainting spell or Syncope
Head trauma that was diagnosed as a concussion or associated with loss of consciousness
Hearing problem, ringing in your ears, eustachian tubes
Cochlear implants
Metal in your brain, skull or elsewhere in your body
Cardiac pacemaker or intracardiac lines
Medication infusion device
None
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Home
About
What We Do
Providers
Office Policies
Blog
Services
TMS for Depression
Contact Us
Request a Refill
COVID-19
