TMS Consult Request Form

Treatment Location (choose one)

408 Healthwest Drive Dothan, Alabama 141 Mack Bayou loop Suite 301 Santa Rosa Beach, Florida

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.

Dothan Behavioral Medicine Clinic

NeuroStar TMS Request Consultation Form

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Dothan Behavioral Medicine Clinic