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TMS: Provider referral form
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Your name and contact information
Your answer
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
Your answer
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