Consent Form for Other Conditions

CONSENT FORM - TMS for Other Conditions | Clinical, Research and Financial Consent

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Patient Name: *

Patient DOB: *

Patient Address:

Patient Phone No: *

Indication for TMS: *

Tinnitus
Migraine
Attention Deficit and Hyperactivity Disorder
Parkinson’s disease
Other

Details:

Adverse effects of magnetic stimulation:

Transcranial Magnetic Stimulation is safe and has few side effects.

Common adverse effects of TMS treatment are as follows:

• Headache
• Scalp discomfort
• Tingling, facial muscle twitching
• Noise related discomfort (patients are offered ear plugs during neuromodulation therapy)

Rare adverse effects of TMS are as follows:

• Seizure (the chance of seizure is one in 30 thousand, which is lower than the seizure rate for patients
treated with antidepressants.)
Please note that in the unlikely event that you do experience a seizure during treatment, this will affect
your fitness to drive.
• Syncope (fainting)
• Mood elevation (elevated mood tends to settle on cessation of treatment)
Unlike electroconvulsive therapy (ECT) TMS causes NO adverse cognitive effects such as memory loss.

Cost of magnetic stimulation:

In Australia, TMS is only covered by Medicare for treatment resistant depression. Unfortunately, there is currently no Medicare support for the use of magnetic stimulation for the treatment of conditions other than depression. This means that patients wishing to access this treatment will need to pay privately for magnetic stimulation treatment with no Medicare rebate being available. At the time of writing there are no private health insurers that will cover the cost of magnetic stimulation for chronic pain, though we encourage you to petition your private health insurers to change this.

Please be aware that the magnetic stimulation fee is not refundable. If you require future maintenance magnetic stimulation therapy or a further treatment cycle, a separate fee will apply.

Your magnetic stimulation treatment cycle quote:

Your number of magnetic stimulation treatments covered by this quote:

Patient Consent

I consent to be involved in the Pioneer Health TMS research project. (Your data would be used for the purposes of research, publications and case reports in a de-identified manner): *

I verify that I have read and understood the above information and that I have had sufficient opportunity to discuss my magnetic stimulation therapy with the doctor.

I verify that I have understood the cost of my magnetic stimulation treatment cycle, and that I have agreed to pay the full quoted treatment cycle fee. I understand that non-payment of the quoted fee will result in cessation of the magnetic stimulation therapy. I also understand that the treatment cycle fee is non-refundable.

Patient’s Name: *

Patient Signature: *

Date:

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CONSENT FORM - TMS for Other Conditions | Clinical, Research and Financial Consent

CONSENT FORM - TMS for Other Conditions | Clinical, Research and Financial Consent

Adverse effects of magnetic stimulation:

Cost of magnetic stimulation:

Patient Consent

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