Transcranial Magnetic Stimulation referral form

TMS referral form

Patient First Name

Please enter the details of the young person being referred.

Patient Surname

Patient date of birth?

RiO Number

NHS number

Named Health Professional

Consultant in Charge

Team Name

Referrer Name

Referrer email address

Date of Referral

Reason for Referral

What is the diagnosis? Why do you think TMS might be helpful?

Risks or Safety Concerns

You MUST confirm…

The patient will be able to attend our clinic at 86 Old Montague Street, Monday to Friday, for several weeks.

The patient does not have any metallic implants in their head

The patient does not a history of epilepsy

The patient does not have a cardiac pacemaker

The patient does not have a cochlear implant

A standard course of treatment is 5 days a week for 6 weeks.
We are only able to consider patients who are actively supported by the referring team.
We expect the referring team to manage any problems arising from mood fluctuations that might occur during treatment.
We do NOT provide overall patient care.
We will stop the treatment (whether acute or maintenance) if we think that the patient is not benefitting, or if the patient is discharged by your team.