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Referral Form

Specialty Services

Name(Required)
MM slash DD slash YYYY
Declaration Field
This field is for validation purposes and should be left unchanged.

Directions: Please fill out this form in its entirety (Any section with an * is required, info is critical for prior authorization) Once complete please return to the form via: Fax: 260-800-1512 or info@vikingpsychiatry.com

Referrer Information: *

Name(Required)
Please check preferred method of communication:(Required)

Patient Information: *

Name(Required)
DD slash MM slash YYYY
Please check preferred method of communication:(Required)
Condition for which rTMS is being requested:(Required)

Past Medication Trials (please list all past medication trials for depression)

Diagnoses (please list all diagnoses)

Past Medication Trials(Required)
Medication
Dose
Response / Side Effects / Reason for Discontinuation:
 

Current Medications (please list all current medications)

Current Medications(Required)
Medication
Dose
Current Response / Side Effects
 
This field is for validation purposes and should be left unchanged.

Patient Referral for SPRAVATO® Treatment

Street Address(Required)

1. PATIENT INFORMATION

Name(Required)
DD dash MM dash YYYY
Address(Required)
*Can a voicemail be left at this number for an appointment?
Policyholder Name(Required)
Caregiver’s Name(Required)

2. MEDICAL HISTORY

List
Medical/Treatment History:
Medications History:
 
Additional medical reports and supporting documents are included with this form.

3. REFERRING HEALTHCARE PROVIDER INFORMATION

Name(Required)
Please notify me with updates regarding my patient through:
Please see full Prescribing Information, including BOXED WARNINGS, and Medication Guide for SPRAVATO®
This field is for validation purposes and should be left unchanged.