South Australia Referrals

TMS Referrals for Modalis clinics in SA

Referring your patients to us is simple and convenient, you have three options:

• Use our online referral form provided below
• Download our PDF referral form
• Additionally, you can access our embedded referral option in your Best Practice medical practice software under the name ‘TMS Modalis Direct Referral’.

TMS is delivered as part of the broader clinical care coordinated by the referrer. Therefore, we will report back to you on the patient’s progress and any other issues arising during the course of the TMS treatment, for the continued care of the patient.

Online Referral Form:

Direct Referral For Transcranial Magnetic Stimulation (TMS) (SA clinics)

Patient Details

First Name(Required)

Surname(Required)

DOB(Required)

Address(Required)

Suburb(Required)

State(Required)

Postcode(Required)

Telephone (Mobile)(Required)

Telephone (Home)

Email

Current Status

Outpatient

Inpatient

Indication for TMS

Specialist Consultation/Treatment if indicated:(Required)

Depression

OCD

PTSD

Pain Management

Other Indications

Other Indications:

Main reason for treatment:(Required)

Minimal to no response to medication

Previous good response to rTMS

Poor tolerability to medications (side effects)

Other (Please Specify)

Other Reasons:

Has the patient undergone any previous neurostimulation (i.e. rTMS or ECT)?

Yes

No

rTMS - how many times:

ECT - how many times:

Other concurrent treatment:(Required)

Psychopharmacology

Psychotherapy

Exercise physiology

Coaching and mentoring

Other (Please Specify)

Other Treatments:

Has the patient adequately trialled at least 2 classes of antidepressants without satisfactory improvement?(Required)

Yes

No

Patient was contraindicated

Has the patient undertaken psychological therapy, if clinically appropriate?(Required)

Yes

No

Not clinically appropriate

Potential risks:

Epilepsy/history of seizures

Eye injuries

Pacemaker or any other implantable medical devices

Neurosurgery

Cochlear implant

Previous problems with TMS

Suicide

Aggression/Agitation

Allergies/Other risks:

No

Yes (Please Specify)

Specify

Additional Information:

Referring Practitioner

Referrer's Name(Required)

Provider No.(Required)

Referrer Type(Required)

General Practitioner (GP)

Psychiatrist

Pain Specialist

Other Specialist Doctor

Other Allied Health Professional

Practice Address(Required)

Contact No.(Required)

Email(Required)

Doctor's Signature(Required)

Date

REFERRER’S PLEASE NOTE: TMS PROTOCOL - TMS PLANNING FOR NEURONAVIGATION. T1 WEIGHTED MRI TO COVER NOSE, EAR AND POSTERIOR HEAD. SLICE DISTANCE 1MM. IN-PLANE RESOLUTION 1X1MM². PLEASE IDENTIFY BILATERAL HAND KNOBS, BILATERAL DLPFC, CZ POINTS AND BILATERAL FACE AREAS.

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