Patient Registration Form

Registration form

"*" indicates required fields

Step 1 of 11

Which location would you like to schedule an appointment with?*

Patient Information

Patient's Name:*

First Last

Patient's Date of Birth:*

Month

Day

Year

Patient's Address:*

Street Address Address Line 2 City State ZIP Code

Home Phone:

Cell Phone:*

Email:

Employer:*

Work Phone:

Marital Status:

Single

Married

Divorced

Separated

Widow

Gender:

Male

Female

Primary Physician:*

Physician Phone:*

This field is hidden when viewing the form

Preferred Pharmacy:

Source of Referral:*

Emergency Contact Information

Emergency Contact's Name:*

First Last

Phone:*

Relationship to Patient:*

Insurance Information

Primary Insurance Company Name:

Insurance Company Phone:

Policy Holder's Name:

Policy Holder's Date of Birth:

Month

Day

Year

Relationship to Patient:

EDI/Payer ID:

Policy Holder's ID#:

Group #:

Claims Address:

Street Address Address Line 2 City State ZIP Code

Insurance Card:

Please upload a photo of the front and back of your insurance card.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

Purpose of Evaluation

Which treatment option are you interested in?*

TMS

Spravato

Why are you interested in treatment with TMS or Spravato?*

Please list prior psychiatric diagnoses:*

Past Medical History

Have you ever been diagnosed with a medical conditiion?*

Yes

Please list medical condition(s):*

Have you ever been hospitalized?*

Yes

Please list dates of hospitalization and for what conditions:*

Have you ever had surgery?*

Yes

Please list surgeries:*

Are you currently taking any medications?*

Yes

Please list medications and dosages:*

Do you have any allergies to medications?*

Yes

Please list medication allergies:*

Do you have a history of hypertension, aortic dissection, aneurysm, or myo cardial infarction? *

Yes

Are you pregnant or breastfeeding?

Yes

Are you taking birth control?

Yes

Are you postmenopausal?

Yes

When was your last menstral period? (Date)

Do you have any history of increased cerebrospinal fluid (CSF) pressure?

Yes

Do you have any history of negative reactions to Ketamine or any other anesthetic medications?

Yes

Patients with any type of non-removable metal in their heads (with the exception of braces or dental fillings), should not receive TMS. Failure to follow this rule could cause the object to heat up, move, or malfunction, and result in serious injury or death.

Do you have any of the following: Aneurysm clips or coils, cardiac pacemaker, Internal cardioverter defibrillator (ICD), carotid or cerebral stents, vagus nerve stimulator?*

Yes

Do you have any of the following: Metallic devices implanted in your head, dental implants, or other metal?

Yes

Have you ever had a complication from an MRI?*

Yes

Do you have an electrode to monitor brain activity?*

Yes

Do you have any shrapnel or bullet fragments in or near the head?*

Yes

Do you have any facial tattoos with metallic or magneticsensitive ink?*

Yes

Family History

Has any family member experienced Depression?*

Yes

Depression – Relationship to Patient:*

Has any family member experienced Axiety?*

Yes

Axiety – Relationship to Patient:*

Has any family member experienced Seizure Disorder?*

Yes

Seizure Disorder – Relationship to Patient:*

Has any family member experienced Aneurysms or Strokes?*

Yes

Aneurysms/Strokes – Relationship to Patient:*

Has any family member experienced Bipolar Disorder?*

Yes

Bipolar Disorder – Relationship to Patient:*

Has any family member experienced Schizophrenia?*

Yes

Schizophrenia – Relationship to Patient:*

Has any family member experienced other mental health diagnoses?*

Yes

Other Mental Health Diagnoses – Relationship to Patient:*

Has any family member experienced heart or blood pressure problems?*

Yes

Please describe heart or blood pressure problem(s):*

Heart or Blood Pressure Problems – Relationship to Patient:*

Has any family member experienced other medical problems?*

Yes

Please describe other medical problems?*

Other Medical Problems – Relationship to Patient:*

Prior Treatment History

We are happy to provide a consultation for you to discuss available treatment options.

In order for us to properly assess your eligibility, we request a detailed treatment history. This information will be required by your insurance company if seeking authorizations, so please be as accurate as possible. We realize that you might not remember all of the details; consulting others who are familiar with your condition(family members or friends), your prior records, as well as pharmacy refill records can help complete the list.

Please check the medications you have tried and in the comments include dosage and approximate length of treatment and outcome.

Please complete this section to the best of your ability. If some details are difficult to recall, give your best estimate.

SSRIs (Selective Serotonin Reuptake Inhibitors):

Prozac (fluoxentine)

Zoloft (sertraline)

Paxil (paroxetine)

Celexa (citalopram)

Lexapro (escitalopram)

Luvox (fluvoxamine)

Other

SSRIs Medication Treatment:*

Click the “+” sign to add medications.

Medication Name

Dates Taken

Highest Dosage

Benefits, Side Effects, Reason for Stopping

SNRIs (Selective Serotonin & Norepinephrine Reuptake Inhibitors):

Effexor (venlafaxine)

Pristiq (desvenlafaxine)

Cymbalta (duloxetine)

Fetzima (levomilnacipran)

Other

SNRIs Medication Treatment:*

Click the “+” sign to add medications.

Medication Name

Dates Taken

Highest Dosage

Benefits, Side Effects, Reason for Stopping

Atypical Antidepressants:

Wellbutrin (Bupropion)

Remeron (Mirtazapine)

Serzone (Nefazadone)

Desyrel (Trazodone)

Viibryd

Trintellix

Other

Atypical Antidepressants Medication Treatment:*

Click the “+” sign to add medications.

Medication Name

Dates Taken

Highest Dosage

Benefits, Side Effects, Reason for Stopping

Tricyclic Antidepressants:

Elavil (amitriptyline)

Tofranil (imipramine)

Pamelor (nortriptyline)

Norpramin (desipramine)

Vivactil (protriptyline)

Asendin (amoxapine)

Sinequan (doxepin)

Other

Tricyclic Antidepressants Medication Treatment:*

Click the “+” sign to add medications.

Medication Name

Dates Taken

Highest Dosage

Benefits, Side Effects, Reason for Stopping

MAIOs (Monoamine Oxidase Inhibitors):

Nardil (phenelzine)

Parnate

Emsam Patches

Other

MAOIs Medication Treatment:*

Click the “+” sign to add medications.

Medication Name

Dates Taken

Highest Dosage

Benefits, Side Effects, Reason for Stopping

Antipsychotics:

Ability (aripiprazole)

Seroquel (quetiapine)

Risperdal (risperidone)

Zyprexa (olanzapine)

Geodon (ziprasidone)

Saphris (asenapine)

Latuda (lurasidone)

Invega (paliperidone)

Vraylar (cariprazine)

Other

Antipsychotics Medication Treatment:*

Click the “+” sign to add medications.

Medication Name

Dates Taken

Highest Dosage

Benefits, Side Effects, Reason for Stopping

Mood Stabilizers:

Lithium

Depakote

Tegretol (carbamazepine)

Trileptal (oxcarbazepine)

Lamictal (lamotrigine)

Other

Mood Stabilizers Medication Treatment:*

Click the “+” sign to add medications.

Medication Name

Dates Taken

Highest Dosage

Benefits, Side Effects, Reason for Stopping

Augmentation Agents:

Synthroid, Levoxyl, Cytomel, Armour Thyroid, etc.

Psychostimulants (Ritalin, Adderall, Dexedrine, Vyvanse, Provigil, Nuvigil)

Buspar (buspirone)

Deplin (L-methylfolate)

Other

Augmentation Agents Medication Treatment:*

Click the “+” sign to add medications.

Medication Name

Dates Taken

Highest Dosage

Benefits, Side Effects, Reason for Stopping

Other Treatments

Supportive Therapy

Cognitive Behavioral Therapy

DBT

EMDR

Electroconvulsive Therapy (ECT, Shock Therapy)

Transcranial Magnetic Stimulation (TMS)

Psychiatric Admissions or Partial Hospitalization Treatments

Ketamine Infusions

Sparvato (esketamine)

Other

Other Treatment:*

Click the “+” sign to add medications.

Treatment Name

Dates Attended

Provider Name

Efficacy & Reason for Stopping

Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things:*

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depreseed, or hopeless:*

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much:*

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy:*

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating:*

Not at all

Several days

More than half the days

Nearly every day

Feel bad about yourself – or that you are a failure or that you have let yourself of your family down:*

Not at all

Several days

More than half the days

Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidety or restless that you have been moving around a lot more than usual:*

Not at all

Several days

More than half the days

Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual:*

Not at all

Several days

More than half the days

Nearly every day

Thoughts that you would be better off dead or hurting yourself:*

Not at all

Several days

More than half the days

Nearly every day

How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Suicide Risk Assessment

In the past few weeks, have you wished you were dead?*

Yes

In the past few weeks, have you felt that you or your family would be better off if you were dead?*

Yes

In the past few weeks, have you been having thoughts about killing yourself?*

Yes

Have you ever tried to kill yourself?*

Yes

How?*

When?*

Are you having thoughts of killing yourself right now?*

Yes

Financial Agreement

Financial Agreement Consent

I agree to pay in full, at the time of service, for all services rendered for myself or my child by Axon TMS for any out-of-network services. I understand that there is a document available upon request regarding the Fee Schedule and any financial obligations, and I have read and agree with the information in this document.

I also understand and agree to pay for any services related to legal matters, including but not limited to depositions, attorney phone calls, and court testimony; these services may be a different pay rate.

I also understand and agree to pay for services including record retrieval, phone consultation, and email consultation as requested by the provider.

I understand that I am responsible for notifying AxonTMS of any change in insurance throughout the course of TMS. I will be financially responsible for any fees not covered by insurance should I neglect to update this information.

I have read and agree to the financial agreement.

Consent to Treat

I hereby authorize Axon TMS and its respective personnel to provide evaluation and treatment.
I understand that these services are not guaranteed as to results, that no guarantees have been provided by Axon TMS, and that there are certain risks involved with these services. I understand that I can terminate this consent for treatment by requesting termination in writing.

I hereby consent to treatment

Privacy Acknowledgment

Privacy Acknowledgement Consent

I understand that the patient’s health information is private and confidential. I understand that with this consent, I give permission for aspects of my healthcare information to be shared with Axon TMS as is necessary for services to be provided. I understand that Axon TMS may use and disclose the patient’s personal health information to help provide care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission. By law, Axon TMS must report actual or suspected child or elder abuse to the appropriate authorities. In addition, Axon TMS is legally bound to take appropriate action if my child or I threaten anyone with violence, harm, or dangerous actions. I understand that there is a detailed document titled “Notice of Privacy Practices” that contains more information about the policies and practices protecting my privacy. I understand that I have the right to read the “Notice” before signing this acknowledgement. I am aware that a copy of this notice will be given to me upon my request. Axon TMS has established procedures which help meet patient obligations. These procedures may include other signature requirements, written acknowledgements, and authorizations; reasonable time frames for requesting information; charges for copies and non-routine information needs, etc. I will assist Axon TMS by following these procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices”. My signature below indicates that I have been given the chance to review a current copy of the “Notice of Privacy Practices”.

I agree to the privacy policy.

Date