TMS form for intakes

TMS INQUIRY FORM

Name

First Name

Last Name

Phone

(###)

###

####

Email

DOB (MM/DD/YYYY):

Do you have any metallic plate/device implanted in head, neck, chest or other areas:

Select any of the symptoms that apply:

PTSD

Migranes

Seizures

ADHD

Depression

Chronic Pain

Message

Thank you for choosing MIU CENTER. Please fill out the form below for TMS inquiry and consultation.