TMS is an FDA-indicated treatment for Major Depression Disorder in individuals who have failed to respond adequately to four anti-depressant medicative therapies.
Patient Information
First Name
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Last Name
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Date of birth
Phone
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Provider Information
Referring Provider
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NPI Number
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Provider Phone
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Provider Email
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Office Fax
Medical Information
Have You discussed TMS as a treatment option with the patient?
Yes
No
Does the patient have one of the following ICD-10 Diagnosis codes? Correct
F32.2
F33.2
Has the Patient tried at least 4 antidepressant medications?
Yes
No
Any Prior ECT or TMS treatments?
Yes
No
Please list prior or current antidepressant medications, including max doses, approximate dates of therapy, and any side effects that the patient experienced.
Any non-removable metal objects in or around the patient’s head?
Yes
No
Has the Patient tried at least one course of psychotherapy?
Yes
No
Any history of seizures?
Yes
No
Additional Information provider would like to include:
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