VisionTms - Online Referral Form

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REFERRAL FORM TRANSCRANIAL MAGNETIC STIMULATION (TMS)

Patient Information

Name

DOB

Address

Phone

Medicare/Health Fund

Medicare #

Ref #

Exp Date

Health Fund Name

Number

Recent MRI available

Reason for Referral

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

Other (specify)

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

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

Phone

Signature

Date

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