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TMS: Provider referral form
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Your name and contact information
Your answer
Phone number
Your answer
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Is your patient interested in accelerated or standard TMS?
Your answer
Patient initials
Your answer
Diagnosis you are referring for
Depression
OCD
Anxiety
PTSD
Other:
How would you like to proceed?
Please contact me via the information in #1 to discuss further
Please reach out to my patient (enter their contact info in comments below). I have informed them that they will hear from you.
Additional questions or comments
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