Clinician rTMS Referral Form

This form must be completed by a treating clinician (Physician, NP, Psychologist)

Please correct the errors described below.

ANSR Clinic

Thank you for your referral. If you have any questions about rTMS Treatment, please do not hesitate to call or email us.

902-466-2677
902-455-2677 (FAX)
info@ansrclinic.com

Client Information

First name

Last name

Contact phone number

Alternate Phone Number

Email address

Date of birth

Address

What is the Clinical Indication for rTMS?

Please check all that apply

Major Depressive Disorder

Bipolar Disorder

Posttraumatic Stress Disorder

Other

Brief Clinical History (Please attach any reports or Fax reports to 902-455-2677)

Upload any reports you may have or fax to 902-455-2677

Add file

Please upload a file

Current Medications and Doses (Indicate None if not taking medications)

Previous Medication Trials

Please Check off any of these Potential Contraindications to rTMS:

History of Seizures

History of Syncope

Implanted Pacemaker

Cochlear Implant

Cerebral Aneurysm Clip/Coil

Metal Fragment in Eye

Pregnancy

Suicidality

Unstable Medical Disorder

Family History of Epilepsy

Head Trauma

Cardiac Disease or Arrhythmia

DBS or Implanted Device

Medication Infusion Pump

Metallic Implant/Foreign Body

Spinal Surgery

Vulnerability of Hearing

Please describe any of the conditions checked off above

Please list any allergies:

Patient's preferred clinic for treatment

Bedford, NS

Fredericton, NB

St. John's, NL

Referring Clinician Contact Information

Add another emergency contact

Your information will be encrypted.

ANSR Clinic

Thank you for your referral. If you have any questions about rTMS Treatment, please do not hesitate to call or email us.

902-466-2677
902-455-2677 (FAX)
info@ansrclinic.com

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