E: info@regionaltms.com.au

Ph: 6230 3908

F: 6266 3796

Referral Form for Transcranial Magnetic Stimulation

Client information

Name

Date of Birth

Address

Phone Number

Email address:

Referral Information

Dear Duty Psychiatrist,

Indication for TMS

Major Depression OCD PTSD Chronic Pain (neuropathoc) Other

If you ticked "Other," please include the indication:

Does the patient have any of the following?

Metallic implants in the head or neck Aneurysm clips Neurosurgery Cochlear implant Pacemakers and ICDs Past seizures

Reason for Referral:

Referring Practitioner

Name

Clinic Address

Email

Phone

Provider Number

Date

Signature

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