TMS Registration

This information allows us to investigate your health insurance benefits in order to determine eligibility. Please be as thorough as possible.

"*" indicates required fields

Which Location?*

Name

First Last

Date Of Birth:

Phone:

Email:

Address

Street Address City State ZIP Code

Do you have Insurance?

Yes

No

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

No

Secondary Insurance:

Secondary Insurance ID:*

Do you currently have any of the following providers?

A Primary Care Doctor?

Yes

No

A Psychiatrist?

Yes

No

A Therapist?

Yes

No

Primary Care Doctor (Full Name):

Doctor Phone Number:

Current Psychiatrist (Full Name):

Psychiatrist Phone Number:

Therapist (Full Name):

Therapist Phone Number:

Do you have any metal in your head, next or face area? (i.e. a steel plate in your skull)*

Yes

No

Question Answer: Do you have any metal in your head, next or face area? (i.e. a steel plate in your skull)*

Do you have a history of seizures or a seizure disorder?*

Yes

No

Question Answer: Do you have a history of seizures or a seizure disorder?*

Do you have any implants such as a vagus nerve stimulator or a pace make?*

Yes

No

Question Answer: Do you have any implants such as a vagus nerve stimulator or a pace make?*

Is there any chance that you're currently pregnant?*

Yes

No

Question Answer: Is there any chance that you're currently pregnant?*

Are you currently or have you ever been diagnosed with Bipolar Disorder?*

Yes

No

Question Answer: Are you currently or have you ever been diagnosed with Bipolar Disorder?*

Are you currently of have you ever experienced psychotic symptoms such as hallucinations or paranoia?*

Yes

No

Question Answer: Are you currently of have you ever experienced psychotic symptoms such as hallucinations or paranoia?*

Do you have a history of severe head trauma, dementia or tumors in the Central Nervous System (brain)?*

Yes

No

Question Answer: Do you have a history of severe head trauma, dementia or tumors in the Central Nervous System (brain)?*

Do you currently have any issues with substance abuse/addiction?*

Yes

No

Question Answer: Do you currently have any issues with substance abuse/addiction?*

Please list your current medication:

1. Name:

Dose:

Approximate State Date:

2. Name:

Dose:

Approximate State Date:

3. Name:

Dose:

Approximate State Date:

4. Name:

Dose:

Approximate State Date:

Please check the medications below that you've tried in the past:

Drug Choice 1

Abilify (aripiprazole)

Lithium (eskalith)

Tegretol (carbamazepine)

Equettro (carbamazepine XR)

Lamictal (lamotrigine)

Rexulti (brexpiprazole)

Trileptal (oxacarbazepine)

Latuda (lurasidone)

Please list any other medications not mentioned above:

How did you hear about us?

Internet

Social Media

Psychology Today

Word Of Mouth

Medical Provider/Hospital

Other

Which Medical Provider/Hospital?

Other - Please explain:

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