VisionTms - Online Referral Form

Patient Information

Name

DOB

Address

Phone

Reason for Referral

Recent MRI available

Initial TMS course with MRI-guided neuronavigation for Treatment-Resistant Depression (TRD)

Re-treatment TMS course following initial TMS course

Booster TMS course following a previous TMS course

TMS course for non-TRD major depressive disorder or where patient does not satisfy Medicare eligibility criteria

TMS course for TRD without MRI-guided neuronavigation due to MRI being unsuitable for this patient

Psychiatric review

Other (specify)

Other reason

Medicare Rebate Eligibility for Brain MRI

Chronic headaches

Unexplained seizures

Neither

Unsure

Medicare Rebate Eligibility Criteria for Treatment-Resistant Depression (TRD)

Have not received TMS previously (if initial course)

Received initial TMS course more than 4 months ago (if re-treatment course)

Diagnosed with major depressive disorder

Over 18

Undertaken psychological therapy if clinically required

No significant improvement after trialling at least 2 classes of antidepressant medications at therapeutic doses for at least 3 weeks, unless contraindicated

Medical History

Including whether there is any history of seizures, cochlear implant, intracranial implants, brain surgery, hearing impairment or substance abuse.

Referring Doctor Information

Name

Medical Provider No

Address

Phone

Date

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