Online Referrals Patient Details First Name * Last Name * Date of Birth * Preferred Contact Method MobileEmail Street Address Suburb Postcode Mobile Email Alternative Contact (Optional) Contact Name Relationship Phone Number Funding Information Medicare Number Ref Valid Until Funding Type Private Health FundSelf FundedDVAWorkCover Private Health Fund Name (if applicable) Referral Information Reason for Referral Major Depressive Disorder Other Reason Eligibility Trialled 2 or more classes of antidepressantsPatient has not had TMS treatment before and may be eligible for Medicare rebate Precautions / Contraindications PacemakerStrokeEpilepsyCochlear ImplantMetal Implant in HeadVP ShuntRetinal Detachment Additional Clinical Information Please include comorbidities, current medications, previous antidepressants trialled, treatment history and any other relevant clinical notes. Referring Practitioner Practitioner Type GPPsychiatristOther Name * Provider Number * Practice Address Phone * Fax Email * Upload Referral Letter / Supporting Documents (Optional) I confirm the patient has consented to this referral and the information provided is accurate.
