TMS Referral form - Elevating mental wellness with compassion

Fill The TMS Referral Form

Please use this form to request a TMS Consultation

Patient Information

Name of Patient:

Patient Email:

Date of Birth:

Requesting: TMS Consult

Please also provide the following records:

Patient Demographic Sheet:

Patient Clinical Notes From the last 1 Year:

Patient's Current/Inactive Medications:

IMPORTANT: You will remain the Patient’s Primary Care Physician/Psychiatrist/Healthcare Provider and will need to continue to provide follow-up during and after the course of treatment. IntegriTMS will not treat the Patient outside of their TMS treatment. IntegriTMS will keep you regularly informed of your Patient’s progress throughout the course of their therapy. We will strongly encourage your Patient to maintain all appointments you have scheduled with them.

Referring Physician’s Information

Name of the Referring Physician:

Clinic Name (if applicable):

Clinic Address:

Physician Specialty:

Phone Number:

Secure Fax Number: