Dothan Behavioral Medicine Clinic
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NeuroStar TMS
Careers
Home
Welcome From Our Medical Director
Medication Policy
Printable clinic forms
Our Team
Our Services
Spravato
Clinic
Therapy
Counseling
Testing
Televisits
Research
QEEG
FAQ
Harmonex Neuroscience Research
CliniCom
NeuroStar TMS
Careers
TMS Consult Request Form
NeuroStar TMS Request Consultation Form
Full Name
Email
Phone Number
Age
Date Of Birth
Primary Insurance
Member's ID
Subscriber's Name
Address
City
State
ZIP
Treatment Location (choose one)
408 Healthwest Drive Dothan, Alabama 36303
141 Scouting Circle Troy, Alabama 36081
All current medications (for medical conditions) and doses.
List all antidepressants tried you must include max dosage and date range month & year, and any side effects of each medication (TMS coverage requires at least 2 antidepressant trails )
Pregnant / Breast feeding?
Yes
No
Member has a confirmed diagnosis of severe major depressive disorder, single or recurrent
Yes
No
Inability to tolerate psychopharmacologic agents as evidenced by four trials of psychopharmacologic agents from at least two different agent classes, at or above the minimum effective dose and duration (at least one of which is in the antidepressant class), with distinct side effects, or
Yes
No
History of response to TMS in a previous depressive episode or currently receiving Electroconvolsive therapy (ECT), and TMS is concidered a less invasive treatment option.
Yes
No
Please mark if the patient has any of the below:
Seizure disorder or any history of seizures (except those induced by ECT or isolated febrile seizures in infancy without subsequent treatment or recurrence)
Yes
No
Current or known substance use at time of referral or start of TMS treatments
Yes
No
Neurological conditions that include epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary or secondary tumors in the central nervous system or Presence of an implanted magnetic - sensitive medical device located less than or equal to 30 cm from the TMS magnetic coil or other implanted metal items including, but not limited to, a cochlear implant, implanted cardiac defibrillator (ICD), pacemaker, vagus nerve stimulation (VNS), or metal aneurysm clips, coils, staples, or stents
Yes
No
History of Psychotherapy required. Please list the name of the therapist/counselor and date range month(s) and which year(s) of visit.
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