Transcranial Magnetic Stimulation (TMS) Informed Consent

# Transcranial Magnetic Stimulation (TMS) Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Provider / Practice:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Treating Clinician(s) **Supervising Psychiatrist / Provider:** ___________ **TMS Technician / Operator:** ___________ **Facility / TMS Suite:** ___________ --- ## 2. Diagnosis and Indication **Psychiatric Diagnosis:** ___________ **FDA-Cleared Indication Being Treated:** ___________ **Reason TMS Is Recommended:** ___________ --- ## 3. TMS Device and Protocol **Device / Manufacturer:** ___________ **Protocol:** ___________