Transcranial Magnetic Stimulation (TMS) Informed Consent and Pre-Treatment Screening

Foundation Psychiatry, P.C. -- 35 Collier Road NW, Suite 425, Atlanta, GA 30309 -- Tel: (404) 902-6184 | Fax: (404) 400-1952

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Effective Date: [09/17/2026] | Version: 1

Transcranial Magnetic Stimulation (TMS): Informed Consent and Pre-Treatment Screening

Patient Information

First and Last Name

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Date of Birth

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Gender

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About Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation (TMS) is a non-invasive, FDA-cleared treatment that uses magnetic pulses to stimulate areas of the brain associated with mood regulation. A typical course of treatment involves sessions five days a week over several weeks, with each session lasting approximately 20 to 40 minutes. TMS does not require anesthesia or sedation, and most patients return to normal activities immediately after each session.

Purpose and Expected Benefits

TMS is intended to reduce symptoms of depression, particularly for patients who have not achieved adequate relief from one or more antidepressant medications. Many patients experience gradual improvement in mood, energy, and concentration over the course of treatment. As with any medical treatment, individual results vary, and TMS may not be effective for every patient.

Risks and Possible Side Effects

Most side effects of TMS are mild and temporary. Possible risks and side effects include: scalp discomfort or pain at the treatment site, particularly during the first week of treatment; headache; facial muscle twitching or discomfort during treatment; lightheadedness; temporary changes in hearing if ear protection is not properly used during treatment; rare risk of seizure (uncommon, occurring in a small fraction of a percent of patients); rare risk of syncope (fainting). Your provider will discuss your individual risk factors with you, including any findings from the screening questionnaire below.

Alternative Treatments

Alternatives to TMS may include continued or adjusted medication management, psychotherapy, esketamine (Spravato), electroconvulsive therapy (ECT), other treatment approaches, or no additional treatment at this time. Your provider can discuss the risks and benefits of these alternatives with you.

Patient Initials (page 1)

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Voluntary Consent and Right to Withdraw

Your decision to undergo TMS is voluntary. You may ask questions at any time before or during treatment, and you may withdraw your consent and stop treatment at any time without it affecting your ability to receive other care at this practice.

Pre-Treatment Screening Questionnaire

Please answer each question completely and truthfully. If you answer “Yes,” please provide details in the space provided. This information helps your provider assess whether TMS is safe and appropriate for you.

1) Do you have epilepsy?

Yes

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If yes, please specify

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2) Have you ever had a convulsion or a seizure?

Yes

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If yes, please specify

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3) Does someone in your family have epilepsy?

Yes

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If yes, please specify

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4) Have you ever lost consciousness without any known reason?

Yes

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If yes, please specify

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5) Have you ever had a severe head trauma?

Yes

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If yes, please specify

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6) Have you ever had a stroke?

Yes

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If yes, please specify

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7) Have you ever undergone surgery on your head?

Yes

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If yes, please specify

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Medical & Neurological History

8) Do you have any of the following implants in your body?

(Metal) plates and/or screws

Yes

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Vascular clips

Yes

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Artificial heart valve

Yes

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Metallic splinters, shrapnel, or similar

Yes

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Pacemaker

Yes

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Insulin pump

Yes

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Internal hearing aid (cochlear implant)

Yes

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Any other implant not listed above

Yes

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If yes (any implant above), please specify

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9) Do you have any known deviations in the spinal cord, bone marrow, or the ventricular system (spaces in the brain filled with fluid)?

Yes

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If yes, please specify

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10) Do you have any hearing disabilities or ringing in your ears?

Yes

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If yes, please specify

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11) Have you ever, at present or in the past, suffered from a brain-related neurological illness?

Yes

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If yes, please specify

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12) Do you suffer from frequent, severe headaches?

Yes

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If yes, please specify

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13) Are you currently under any other form of medical treatment?

Yes

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If yes, please specify

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14) Are you currently taking antibiotics?

Yes

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Medications, Psychiatric & Substance History

15) Do you ever take antihistamines (anti-allergy medication)?

Yes

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If yes, please specify

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16) Are you taking any other medications not mentioned above?

Yes

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If yes, please specify

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17) Do you have a chronic illness or disorder?

Yes

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If yes, please specify

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18) Have you ever, at present or in the past, had a psychiatric illness or disorder?

Yes

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If yes, please specify

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19) Does someone in your family have a psychiatric illness or disorder?

Yes

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If yes, please specify

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20) Have you used any recreational drugs during the past year?

Yes

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If yes, please specify

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21) Have you ever suffered from substance dependence or abuse?

Yes

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If yes, please specify

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22) Do you consume, on average, more than 3 alcoholic drinks per day?

Yes

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23) Do you have sleeping problems?

Yes

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If yes, please specify

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Additional Screening

24) Are you pregnant, or is there a chance that you might be?

Yes

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27) Has your doctor discussed the risks of TMS with you, as described above?

Yes

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25) Have you ever undergone an MRI for clinical purposes?

Yes

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25) If yes, did any problems occur during scanning?

Yes

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If yes, please specify

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26) Have you ever undergone TMS before?

Yes

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26) If yes, did you have any adverse reaction?

Yes

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If yes, please specify

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27) Has your doctor discussed the risks of TMS with you, as described above?

Yes

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Consent & Authorization

I confirm that I have answered all screening questions truthfully and to the best of my knowledge. I confirm that I have read, or had explained to me, the information above regarding the purpose, benefits, risks, and alternatives to TMS. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand that my participation is voluntary and that I may withdraw my consent at any time without affecting my ability to receive other care at this practice.

If deemed medically appropriate by my physician, I consent to undergo Transcranial Magnetic Stimulation under the care and direction of my physician.

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

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Date

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Patient Initials (final page)

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