TMS Patient Form

Contact Name

Contact Email

Contact Phone Number

How did you hear about us?

Patient Name

Patient Date of Birth

Patient Address

Primary Insurance Provider

Primary Insurance Subscriber

Whose insurance is this?

Primary Insurance Subscriber Birthdate

Primary Insurance ID

Secondary Insurance Provider

Secondary Insurance Subscriber

(Whose insurance is this?)

Secondary Insurance Subscriber Birthdate

Secondary Insurance ID

Please list current or prior psychiatric diagnoses (bipolar, psychosis, schizo exclusions):

Please describe any current or past psychiatric medications:

Please include medication name, if you are currently using the medication, # of weeks using medication, effectiveness, and side effects. (e.g. Prozac, yes, 3 months, somewhat effective, frequent nausea). Use new line for each.

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Who is your current (or most recent) psychiatric provider?

Please provide name, title, and phone number (example: Jane Smith, MD, 123-456-7890)

Please list any therapies you have tried, frequency, and for how long:

(e.g. CBT, weekly, 3 months)

Have you ever had TMS treatment before? If so, what were the results?

Are you qualified for ECT? If so, have you refused ECT treatment and for what reason?

Metal implants? Seizures? Neurological conditions? Hearing implants? Vegas nerve stim?

Brighter Day Psychiatry TMS Clinic | Rose George MD