TMS Patient Intake

TMS Patient Intake
Date:

MonthDayYear
Date
Name:*
Callback number:
Email:*
example@example.com
Date of Birth:*

MonthDayYear
Date
Have you been diagnosed with Major Depressive Disorder (MDD)?*

YesNo
Are there any secondary/co-morbid diagnoses?*

YesNo
If yes, what are they?
Insurance plan(s):*
Member #:
Who is your current psychiatrist/prescriber?*
How long have you been seeing them?
Do you currently have a therapist?*
How long have you been seeing them?
The next few questions are required for your insurance. If you are accepted, we will need this information for your prior authorization. In addition to filling out this form, we will need the past two (2) years of medication history from your pharmacy. Most insurances require at least three (3) different antidepressants from two difference classes, with stricter insurances requiring more.

Medications:*

	Name	What Class of Anti-Depressant	Highest Dose	Length of Time at Highest Dose	Start and End Dates	Response/Side Effects
Medication 1
Medication 2
Medication 3
Medication 4

Depression Scales:*