Neuro Evolution

TMS referral form
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TMS referral

One page. Your patient is contacted within two business days to arrange the psychiatrist assessment, and you receive the assessment report and an end-of-course summary. Fields marked * are required; a standard referral letter with the same details is equally welcome.

Referrer

Name *

Role *

GP Nurse practitioner Psychiatrist Other specialist: ________

Provider number *

Practice *

Phone *

Email for the report *

Patient

Name *

Date of birth *

Phone *

Email (optional)

Funding *

Medicare DVA Private (self-funded) Other: ________

Clinical

Primary diagnosis *

Major depressive disorder Bipolar depression (type I) Bipolar depression (type II) Not depression Other: ________

Adequate antidepressant trials to date * (Medicare requires at least two)

0 1 2 3 4 or more

Previous course of TMS? *

No Yes, responded Yes, did not respond Unsure

Any of the following? (tick any)

Cochlear implant Ferrous metal in head or neck Epilepsy or seizure history Significant head or eye injury Pacemaker or implanted device Neurosurgery Pregnancy Other: ________

Notes (optional): current medications, antidepressants tried, relevant history

Consent

I confirm my patient has consented to Neuro Evolution contacting them to arrange a psychiatrist assessment, and to my practice receiving correspondence about their care. *

Signature *

Date *

To save as a PDF, use your browser's Print and choose Save as PDF. Referrals are used only to arrange the patient's care. The psychiatrist confirms Medicare eligibility at assessment. Urgent or complex case? Call the clinic and a clinician will speak with you the same day.