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Welcome
TMS
Treatment Options
- Depression
- Anxiety
Neurostar
Insurance & Financing
- Apply For Treatment
Contact Us

MAKE AN APPOINTMENT

Welcome
TMS
Treatment Options
- Depression
- Anxiety
Neurostar
Insurance & Financing
- Apply For Treatment
Contact Us

info@mytmscenter.com (800) 680-4453

Welcome
TMS
Treatment Options
- Depression
- Anxiety
Neurostar
Insurance & Financing
- Apply For Treatment
Contact Us

Apply For Treatment

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Apply For Treatment

This HIPPA compliant confidential form will help collect the information needed to get you or your loved one started with our treatments.

"*" indicates required fields

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Insurance*

Have you tried TMS before?*

Yes

No

What is the name of your previous TMS provider?

When did you start your last course of TMS?

MM slash DD slash YYYY

When did you end your last course of TMS?

MM slash DD slash YYYY

Which SSRIs have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced.

Citalopram (Celexa)

Escitalopram (Lexapro)

Paroxetine (Paxil)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Sertraline (Zoloft)

Which SNRIs have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced.

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

Desvenlafaxine (Pristiq)

Levomilnacipran (Fetzima)

Which other anti-depressants have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced.

Vilazodone (Viibryd)

Vortioxetine (Trintellix)

Buproprion (Wellbutrin)

Buspirone (Buspar)

Lithium (Eskalith)

Trazadone

Mirtazapine (Remeron)

Selegiline (Emsam)

Adderall

Spravato

Triidothyronine (T3)

Which tricyclic antidepressants have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced.

Amitriptyline

Nortriptyline

Doxepin

Which atypical antipsychotics have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced.

Lamictal (Lamotrigine)

Lurasidone (Latuda)

Quetiapine (Seroquel)

Aripiprazole (Abilify)

Brexpiprazole (Rexulti)

Olanzapine (Zyprexa)

Risperidone (Risperdal)

Do you have any known drug allergies?

Are you currently in or have you ever tried talk therapy?

Yes

No

What was your provider's name?

When did you begin talk therapy?

MM slash DD slash YYYY

When did you end talk therapy?

MM slash DD slash YYYY

Do you have a history of any of the following:*

Seizures

Cerebrovascular disease

Dementia

Increased intracranial pressure

Traumatic brain injury

Heart attack or cardiac abnormalities

Diabetes

High blood pressure or hypertension

None of the above

Do you have any of the following implants:*

Cardioverter defibrillator

Metal aneurysm clips, coils, staples, or stents

Cochlear implants

Vagus nerve stimulator

Pacemaker

None of the above

Which location are you interested in?

Which service are you most interested in?

TMS Therapy

Ketamine Treatment

Neurofeedback

Comprehensive Program/IOP

What is the name of the individual filling this out?

Preferred Pharmacy Name (optional)

Preferred Pharmacy Address (optional)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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