Screening Form

Full Name *

Date of Birth *

Email *

Contact Number *

Your Location *

Gender *

Pregnancy

Presence of electronic implants (e.g. cochlear implant, pacemaker, insulin pump, clips) *

Have ever had complication from an MRI?

Condition enquiring for. *

Description of Symptoms *

Medication Taken? *

Other Medications Taken? (if not listed above)

History of epileptic episode? *

Suffering from insomnia *

Suffering from migraine? *

When do you prefer your treatment to start?

Please let us know how you found us?

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The rTMS Centre (London) • 4 Devonshire Street, London W1W 5DT • 020 7205 2072

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Brain Stimulation Therapies