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Refer a Patient
Please fill out the form below to refer your patient to
Tompkins TMS
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Please complete the following information so that the NeuroStar provider can contact the patient, and keep you informed on the treatment path.
Patient Information
Patient Name
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Patient Date of Birth
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Referring Provider Information
Provider Name
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Practice Name
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Provider Email
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Provider Specialty
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Psychiatry
Nurse Practitioner / Physician Assistant
Primary Care Physicians (PCPs) / Family Practice
Therapists / Counselors
OBGYN
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Notes
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Neuronetics Privacy Policy.
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