TMS Service Request

Is this patient 18 years of age or older?

Yes

No

Does This Patient Have Major Depressive Disorder (MDD) as a Primary Diagnosis?

Yes

No

Has This Patient Tried 4 Antidepressants in the Current Episode of Depression?

Yes

No

Does This Patient Have Bipolar Disorder, Schizophrenia, or Epilepsy?

Yes

No

Has This Patient Tried Psychotherapy?

Yes

No

Does This Patient Have Metal or Medical Devices Implanted in Their Body?

Yes

No

Patient Name

First

Last

Patient Preferred Name

Patient Date of Birth

Patient Email

Street

City

State

Zip Code

Patient Phone Number

Name of Insurance Company

Is this patient a current or past Ellie client?

Yes

No

If you’re freaking the%#$@ out…