Self-Referral Form | Essex rTMS Service

Patient Information

Name*

First Last

Date of Birth*

NHS Number

Address*

Street Address Address Line 2 City ZIP / Postal Code

Tel*

Mobile

Email*

Name*

First Last

Address*

Street Address Address Line 2 City ZIP / Postal Code

Tel*

Fax

Email

Please explain why you feel you would be a good candidate for rTMS*

Please provide us with information about your current medications and dosage*

Please tick payment method*

Payment must be made at least 5 days prior to the Assessment date. Please call 0800 011 3024 to make payment via debit/credit card.

Name/Company*

Address*

Street Address Address Line 2 City ZIP / Postal Code

By submitting this form you are also consenting to us obtaining medical history and medication information from your GP.*