TMS Therapy Phone Consultation
Clearwave TMS Phone Consultation:
*
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Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Zip Code
Treatment Location Preference
Garden City, NY
Hauppauge, NY
Latham, NY
Middletown, NY
Nanuet, NY
New Rochelle, NY
Poughkeepsie, NY
Valhalla, NY
Kingston, NY
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Have you tried antidepressant medications?
*
Yes, too many antidepressants to count
Yes, 3-5 antidepressants
Yes, 1-2 antidepressants
No
Have you ever been diagnosed with bipolar disorder, psychotic disorder, or schizoaffective disorder?
Yes
No
Do you have any metal in or around the head?
Yes
No
Do you have any metal in or around the head?
Yes
No
Health Insurance Carrier
Is this a Medicare Plan?
Yes
No
Please share any other details to prepare for our consultation.
Submit
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