Transcranial Magnetic Stimulation (TMS) Referral Form

(To be filled out by referring provider)

TMS is a depression treatment that can improve response in patients for which current medication therapies and psychotherapies for major depression have not provided satisfactory results, or persons who have experienced negative side- effects from medications. Please reference links at the bottom of page to review research and standard practice beyond that you can reference on this website.

Must be 18 or older

Does the Patient have a current diagnosis of Major Depression Disorder symptoms?

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Has Patient been treated with at least four (4) medications? (Please List and/or send Medical Records)

Include: Names, Dosage, Dates, Duration, Outcome

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Has patient tried psychotherapy?

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Are you aware of any contraindicators?

Have you discussed and recommended TMS as an option with your patient?

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Other related health concerns (Seizures, Dementia, Stroke, Acute psychosis, Serious Illness, Non-adherence to Tx 

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Additional impressions or comments:

Locations: 

415 South Medical Drive, Suite D101, Bountiful, UT 84010 

327 West Gordon Avenue, Suite 1, Layton, UT 84041

370 E, South Temple, Suite 175, Salt Lake City, UT 84111

5974 S Fashion Pointe Dr., Suite 140, South Ogden, UT 84403

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