MedServ TMS Online Referral

Referrer Information

Title

DrProfOther

Given Name *

Family Name *

Provider Number

Provider Qualification

I would like to be kept inform by:

EmailTelephoneFaxLetter

Practice Phone Number *

Practice Fax Number

Practice Name

Practice Address

Street addressStreet address line 2

City

State

Postcode

Country

Please provide your Email Address *

Patient Information

Patient's given name *

Patient's family name *

Date of Birth *

Patient's Phone Number

Patient's Email

Medicare Number

Medicare Reference Number

Medicare Card Expiry Date

Patient's Address

Street addressStreet address line 2

City

State

Postcode

Country

Funding Source

Alternate Contact NameComplete if there is someone from Monarch Patient Care Team can contact if Care Team is unable to reach the patient.

Alternate Contact Phone Number

Relationship to Patient

Referral Information

Reason(s) for referral

Major depressive disorderGeneralized anxiety disorderObsessive compulsive disorderPost-traumatic stress disorderOther

In the Last 12 months, has this patient :

Trialled 2 or more classes of antidepressants (list under additional Information below)Being admitted for Psychiatric conditionis currently admitted to Hospital

Additional information - include comorbidities, current medication(s) and previous antidepressants trialled if applicable.

Upload Referral letter, If needed.

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The Monarch Clinic Australia Provides Outpatient rTMS Treatment in MedServ Clinic Dandenong. If your patient is in acute crisis which presents a risk to the patient (i.e. is actively suicidal) or others, please contact your local Emergency Department. Submission of an online referral does not automatically constitute acceptance of the referral. Monarch Patient Care Team will contact your patient, and you will be advised of the outcome.

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