TMS Therapy VIP Referral

Patient Full Name*

First NameLast Name
Name of Guardian (if patient is under 18)

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Does the patient consent to receive text messages about their care?*

YesNoUnsure
Email Address
example@example.com
Type of insurance?*
*Colorado Medicaid does not cover Transcranial Magnetic Stimulation (TMS).
Picture of Insurance Card (front and back)*

Cancelof
Please provide the following clinical information:
Current Diagnoses*
TMS is not covered by insurance for Bipolar Disorder
List of Current Medications:
List of Previous Psychiatric Medications:
Name of Current Psychiatrist

First NameLast Name
Name of Current Therapist

First NameLast Name
Referring Provider Email*
example@example.com
Current PHQ-9 Score (if available)
Date of PHQ-9 Score

MonthDayYear
Medical Conditions
Any history of seizure?*
Any implanted metallic objects above the neckline?*
gclid
utm_source
utm_medium
utm_campaign
Should be Empty: