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Name *

First Name

Last Name

Phone No. *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pregnant / Breastfeeding? *

Yes

No

Member has a confirmed diagnosis of severe major depressive disorder, single or recurrent *

Yes

No

Inability to tolerate psychopharmacologic agents as evidenced by four trials of psychopharmacologic agents from at least two different agent classes, at or above the minimum effective dose and duration (at least one of which is in the antidepressant class), with distinct side effects *

Yes

No

History of response to TMS in a previous depressive episode or currently receiving Electroconvolsive therapy (ECT), and TMS is concidered a less invasive treatment option. *

Yes

No

Seizure disorder or any history of seizures (except those induced by ECT or isolated febrile seizures in infancy without subsequent treatment or recurrence) *

Yes

No

Current or known substance use at time of referral or start of TMS treatments *

Yes

No

Neurological conditions that include epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary or secondary tumors in the central nervous system or Presence of an implanted magnetic - sensitive medical device located less than or equal to 30 cm from the TMS magnetic coil or other implanted metal items including, but not limited to, a cochlear implant, implanted cardiac defibrillator (ICD), pacemaker, vagus nerve stimulation (VNS), or metal aneurysm clips, coils, staples, or stents *

Yes

No