Pleasefaxallconsultationrequeststotheattentionof:NINETLAB-FidelVila-Rodriguez,MD,FRCPC,FAPA

Phone:604-827-1361Fax:604-827-0530Address:2ndFloor,2255WestbrookMall,

VancouverB.C.V6T2A1

NINET-IMHCLINICRequestforConsultation

PatientIdentification:

Name:____________________________________________Birthdate:_______________________________________PHN:______________________________________________Tel:________________________AltTel:_____________Email:____________________________________________Address:__________________________________________

ReferringPhysician:

Name:___________________________________________Billing#:______________________________________Tel:______________________________________________Fax:______________________________________________Email:___________________________________________Address:_________________________________________

________________IndicationforrTMS:£ MajorDepressiveDisorder£ BipolarDisorder£ Obsessive-CompulsiveDisorder£ Psychosis£ Other:______________________________

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CurrentMedicationsandDoses:______________________________________________________________________

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BriefClinicalHistory/ComorbidMedicalIssues:

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Previous:☐rTMS☐tDCS☐ECT☐VNS ☐DBS

PotentialContraindicationstorTMS☐Y☐NHistoryofepilepticseizures☐Y☐NFamilyhistoryofepilepsy☐Y☐NHistoryofsyncopalepisodes☐Y☐NHeadtraumawithlossofconsciousness☐Y☐NCardiacdisease☐Y☐NCardiacarrhythmia☐Y☐NImplantedcardiacpacemakerordefibrillator☐Y☐NImplantedDBSorotherneurostimulator☐Y☐NCochlearimplant☐Y☐NMedicationinfusiondevice☐Y☐NAneurysmcliporcoils☐Y☐NMetallicimplantorotherforeignbody☐Y☐NMetalfragmentsineye/historyofmetalwork☐Y☐NHistoryofspinalsurgery☐Y☐NImpairmentorvulnerabilityofhearing☐Y☐NPregnant

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DateofReferral:_______________________SignatureofReferringPhysician:_________________________________