Referral for Transcranial Magnetic Stimulation

    ELUMIND CENTRES FOR BRAIN EXCELLENCE

    Thank you for referring your patient to Elumind Centres for Brain Excellence. TMS is Health Canada approved alternative therapy for treatment-resistant depression, OCD and other brain-based conditions, that uses non-invasive magnetic energy pulses to stimulate the nerve cells in the brain.

    PATIENT INFORMATION
    Name
    DOB
    Personal Health Number
    Phone Number
    Emergency Contact
    Phone Number
    REFERRING PROVIDER INFORMATION
    Name
    Phone Number
    Date of Referral
    DIAGNOSIS
    HISTORY OF
    POTENTIAL CONTRAINDICATIONS MEDICATION HISTORY
    Medication
    Dosage
    Start Date
    End Date
    Effective: Yes/No
    Side Effects

    Medication
    Dosage
    Start Date
    End Date
    Effective: Yes/No
    Side Effects

    Medication
    Dosage
    Start Date
    End Date
    Effective: Yes/No
    Side Effects

    Medication
    Dosage
    Start Date
    End Date
    Effective: Yes/No
    Side Effects