Patient Referral Form

Please use this form to request a TMS / Ketamine Consultation

Patient Information

INSURANCE INFORMATION

(Please disregard if sending pic/scan of front and back of PT’s ins card)

Referring Provider’s Information

REASON FOR REFERRAL

Additional Information

Please provide us with the Patient’s clinical notes from the last 1 year

PDF, JPG or PNG, up to 10 MB. You can also fax them to (224) 848-5254.

PSYCHIATRIC MEDICATION HISTORY

(Please list medications prescribed in the last year. Include dose and approximate duration of use.)

RELEASE OF INFORMATION (ROI)

I authorize the release of my medical information to IntegriTMS Services PLLC for the purpose of coordination of care, evaluation, and treatment with Deep TMS and/or Ketamine therapy. This authorization is valid for one year unless revoked in writing.

Please fax completed form and recent psychiatric notes to:
Fax: (224) 848-5254  |  Questions? Call (224) 848-5253

IMPORTANT: As the patient's primary provider, you will remain responsible for the patient's ongoing care, while IntegriTMS will provide only the services for which the patient has been referred.