Refer a Patient

Working together for patients

If you feel your patient could benefit from TMS Therapy, please fax the completed form with any relevant clinical information to: (502) 792-7292

If you feel your patient could benefit from TMS Therapy, please fax the completed form with any relevant clinical information to: (502) 792-7292

Patient Name:

Phone #:

Address:

Date of Birth:

Insurance Provider:

Insurance Phone #:

Policy Number/ID:

Referring Provider: Address:

Office Phone #:

Office Fax:

Have you discussed TMS as a treatment option with the patient?

Does the patient have one of the following ICD-10 Diagnosis codes? F32.2F33.2Other Diagnosis Code

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