Please fax all consultation requests to the attention of NINET-IMH Clinic Dr. Michael Butterfield, MD, FRCPC | Dr. Fidel Vila-Rodriguez, MD, FRCPC, FAPA Phone: 604-827-1361 Fax: 604-827-0530 Address: Room 1816, First Floor, 2255 Wesbrook Mall Vancouver, BC V6T 2A1 NINET-IMH CLINIC Request for Consultation Patient Identification: _ Indication for rTMS/MST/ECT: £ Major Depressive Disorder £ Bipolar Disorder £ Obsessive-Compulsive Disorder £ Psychosis £ Other: ______________________________ Current Medications and Doses: Previous: ☐ rTMS ☐tDCS ☐ ECT ☐VNS ☐DBS Potential Contraindications to rTMS/MST/ECT: ☐Y ☐N History of epileptic seizures ☐Y ☐N Family history of epilepsy ☐Y ☐N History of syncopal episodes ☐Y ☐N Head trauma with loss of consciousness ☐Y ☐N Cardiac disease ☐Y ☐N Cardiac arrhythmia ☐Y ☐N Implanted cardiac pacemaker or defibrillator ☐Y ☐N Implanted DBS or other neurostimulator ☐Y ☐N Cochlear implant ☐Y ☐N Medication infusion device ☐Y ☐N Aneurysm clip or coils ☐Y ☐N Metallic implant or other foreign body ☐Y ☐N Metal fragments in eye/history of metal work ☐Y ☐N History of spinal surgery ☐Y ☐N Impairment or vulnerability of hearing ☐Y ☐N Pregnant ☐Y ☐N Allergy-Please attach a summary report _________________________________________________________________________________________________________________________ Date of Referral: _______________________ Signature of Referring Physician:_________________________________ Family Doctor: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Referring Physician: Name: ___________________________ Billing #: ________________________ Tel:_______________________________ Fax: ___________________________ Email: ____________________________ Address: _________________________ ____________________________________ Name:___________________________________ DOB:____________________________________ PHN:____________________________________ Phone(H): ____________________________ Cell: _________________________________ Email:____________________________________ Address:_________________________________ ____________________________________________ Occupation: ____________________________ Name: ___________________________ Billing #: ________________________ Tel:_______________________________ Fax: ___________________________ Email: ____________________________ Address: _________________________ ____________________________________ Brief Clinical History/Comorbid Medical Issues: Please provide recent reports.

Request for Consultation · Vancouver, BC V6T 2A1 NINET-IMH CLINIC Request for Consultation ... ☐Y ☐N Metal fragments in eye/history of metal work ☐Y ☐N History of spinal

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Page 1: Request for Consultation · Vancouver, BC V6T 2A1 NINET-IMH CLINIC Request for Consultation ... ☐Y ☐N Metal fragments in eye/history of metal work ☐Y ☐N History of spinal

PleasefaxallconsultationrequeststotheattentionofNINET-IMH Clinic

Dr. Michael Butterfield, MD, FRCPC | Dr. Fidel Vila-Rodriguez, MD, FRCPC, FAPA Phone:604-827-1361Fax:604-827-0530

Address: Room 1816, First Floor,2255WesbrookMallVancouver,BCV6T2A1

NINET-IMH CLINICRequestforConsultation

PatientIdentification:

________________

IndicationforrTMS/MST/ECT:£ MajorDepressiveDisorder£ BipolarDisorder£ Obsessive-CompulsiveDisorder£ Psychosis£ Other:______________________________

CurrentMedicationsandDoses:

Previous:☐rTMS☐tDCS☐ECT☐VNS ☐DBS

PotentialContraindicationstorTMS/MST/ECT:☐Y ☐N History of epileptic seizures ☐Y ☐N Family history of epilepsy ☐Y ☐N History of syncopal episodes ☐Y ☐N Head trauma with loss of consciousness ☐Y ☐N Cardiac disease ☐Y ☐N Cardiac arrhythmia ☐Y ☐N Implanted cardiac pacemaker or defibrillator ☐Y ☐N Implanted DBS or other neurostimulator ☐Y ☐N Cochlear implant ☐Y ☐N Medication infusion device ☐Y ☐N Aneurysm clip or coils ☐Y ☐N Metallic implant or other foreign body ☐Y ☐N Metal fragments in eye/history of metal work ☐Y ☐N History of spinal surgery ☐Y ☐N Impairment or vulnerability of hearing☐Y ☐N Pregnant☐Y ☐N Allergy-Please attach a summary report _________________________________________________________________________________________________________________________

DateofReferral:_______________________SignatureofReferringPhysician:_________________________________

Family Doctor:

_____________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ _______________________________________________________________ _______________________________________________________________

_____________________________________________________________________________________

ReferringPhysician:

Name:___________________________Billing#:________________________ Tel:_______________________________Fax:___________________________Email:____________________________ Address: _________________________ ____________________________________

Name:___________________________________ DOB:____________________________________ PHN:____________________________________ Phone(H): ____________________________Cell: _________________________________ Email:____________________________________Address:_________________________________ ____________________________________________Occupation: ____________________________

BriefClinicalHistory/ComorbidMedicalIssues:Please provide recent reports.