TMS Inquiry
If you are NOT a current patient of Hope419 and are considering TMS as a treatment option for your depression, please provide the following information. We will contact you within 3-5 business days.
* Required
Email address
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Your email
Patient first & last name.
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Your answer
Patient date of birth.
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MM
/
DD
/
YYYY
Phone number where patient can be reached.
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Your answer
Preferred method of communication regarding TMS.
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phone
text
email
Have you tried 3 or more medications for your depression?
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Yes
No
Have you tried talk therapy or counseling for your depression?
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Yes
No
Do you still suffer from depression more days than not?
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Yes
No
Maybe
Would you like to use insurance or self pay for TMS?
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Insurance
Self Pay
Insurance, but I would be willing to pay some out of pocket.
Do you have a pacemaker, cardiac defibrillator, vagal nerve stimulator, aneurysm clips or other ferromagnetic material around your head, neck, or shoulders that would otherwise make you ineligible for an MRI?
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Yes
No
I don't know
I am willing to consider TMS as an option and understand that it is a time commitment. (Treatments are 5 days per week, for 20 minutes, and typically lasts for 6 weeks.
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Yes
No
Not sure, I need more information.
Who is your current psychiatrist, therapist, or family doctor?
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Your answer
Are you interested in becoming a patient of Hope419 for anything other than TMS (medication management, counseling, testing)?
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Yes, I am interested in TMS, but am also interested in starting treatment with Hope419 as well.
No, I am happy with my current clinicians, but would like to pursue TMS treatment for my depression.
Maybe
Send me a copy of my responses.
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