REFERRAL FORM TRANS-MAGNETIC STIMULATION (TMS)

Patient Information

Medicare/Health Fund

Name

Medicare #

DOB

Ref/ Exp Date

Phone

Health Fund

Email

Reason for Referral

Initial Course for Treatment-Resistant Depression (TRD) with Brain MRI + Neuronavigation	Booster course following a previous TMS course of treatment
Major Depressive Disorder (non TRD or does not satisfy Medicare eligibility criteria)	Re-treatment course following initial course of TMS
Other (specify)
Medicare Rebate Eligibility for MRI: Does your patient suffer unexplained seizures	Chronic Headaches

Medicare Rebate Eligibility for MRI

unexplained seizures

Chronic Headaches

Treatment-Resistant Depression (TRD) Medicare Eligibility Criteria

Diagnosed with major depressive disorder	Over 18
Have not received TMS previously (if initial course)	Received initial course more than 4 months ago (if re-treatment course)
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
Please supply any relevant medicare history

Referring Doctor Info

Name

Email

Provider

Signature

Phone

Date