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About Us
Our Services
Accelerated and Traditional rTMS
Approved Nasal Spray Treatment
Conditions We Treat
Our Staff
Dr Sajeeva Jayalath
Dr Ching Long Ho
Dr Antony Moonjelly
Dr Neelya Agalawatta
Resources
Medical Help Lines
Books on ADHD and Anxiety
For GPs
Online Referrals
Contact Us
About Us
Our Services
Accelerated and Traditional rTMS
Approved Nasal Spray Treatment
Conditions We Treat
Our Staff
Dr Sajeeva Jayalath
Dr Ching Long Ho
Dr Antony Moonjelly
Dr Neelya Agalawatta
Resources
Medical Help Lines
Books on ADHD and Anxiety
For GPs
Online Referrals
Contact Us
Login
Book
TMS Online Referral Form
TMS request for treatment.
Patient Details
First Name
Surname
Date of Birth: (DD/MM/YYYY)
Address
Suburb
State
Post Code
Phone
Email
Current status: (please tick)
Inpatient
Outpatient
Indication for TMS
Indication for TMS
Depression
OCD
PTSD
Pain
Other
Main reason for Treatment: (please tick)
Minimal to no response to medication
Previous good response to TMS
Poor tolerability to medications (side effects)
Other
Main reason for Treatment specify
Has the patient undergone any previous neurostimulation (i.e. rTMS or ECT)?
Yes
No
Other concurrent treatment(s):
Psychopharmacology
Psychotherapy
Coaching and Mentoring
Exercise Physiology
Other
Other concurrent treatment(s) Specify
Has the patient trialled at least 2 classes of antidepressants without satisfactory improvement?
Yes
No
Not Clinically appropriate
Potential Risks
Epilepsy/Seizures
Eye injury
Pacemaker or other implantable device
Neurosurgery
Cochlear implant
Previous problems with TMS
Aggression/ Agitation
Suicide attempts/suicidal ideation
Allergies/Other risks
No
Yes
Allergies/Other risks specify
Additional Information
Referring Practitioner
Referrer’s Name
Provider Number
Practice Address
Contact No
Email
Referrer Type
General Practitioner (GP)
Psychiatrist
Other Specialist Doctor
Upload Dr Referral and any relevant documentation.
Max file size: 25MB
File Upload
Date
Signature
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