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Medication Policy
Our Team
Our Services
Clinic
Therapy
Pharmacy
Counseling
Testing
Televisits
Research
QEEG
FAQ
Harmonex Neuroscience Research
New Patients
Welcome From Our Medical Director
Request New Patient Appointment
CliniCom
Contact Us
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NeuroStar TMS
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NeuroStar TMS request form
"
*
" indicates required fields
Full Name
*
Age
*
Birthdate
*
MM slash DD slash YYYY
Phone
*
Email
*
Primary Insurance
*
Member's ID
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Subscriber's Name
*
Address
*
Street Address
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State
ZIP Code
Treatment Location (choose one)
*
Dothan, AL
Miramar Beach, FL
Treatment for
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Major Depressive Disorder
obsessive-compulsive disorder
All current medications (for psychiatric or other medical conditions) and doses:
*
List all Antidepressants attempted
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Maximum dose for each Medication tried
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Date range of trial for each Medication tried
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Side Effects / ineffective for each medication tried
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Member is not pregnant or breast feeding
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Yes
No
Member has a confirmed diagnosis of severe major depressive disorder, single or recurrent
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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
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Yes
No
History of Psychotherapy required. Please list the name of the therapist and date range of visit.
*
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