info@tmsofemeraldcoast.com
850-254-9575

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TMS PRE-CERTIFICATION MEDICATION LIST

TMS PRE-CERTIFICATION MEDICATION LIST

Name

Date of Birth

Phone Number

Email

Amitriptyline (Elavil)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Imipramine(Tofranil)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Oesipramine(Norpramin/Pertofrane)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Trimipramine(Surmontil)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Clomirpamine(Anafranil)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Maprotiline (Ludiomil)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Doxepin (Sinequan)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Nomifensine (Merital)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Nortriptyline (Pamelor/Aventyl)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Protriptyline (Vivactil)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Amoxapine (Asendin)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Mirtazapine (Remeron)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

SSRI

Fluoxetine (Prozac)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Citalopram (Celexa)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Fluvoxamine (Luvox)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Paroxetine (Paxil)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Paroxetine CR (Paxil CR)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Sertraline (Zoloft)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Escitalopram (Lexapro)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Vortioxetine (Brintellix/Trintellix)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Volazodone (Viibrid)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

SNRI

Venlafaxine (Effexor) IR/XR

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Duloxetine (Cymbalta)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Desvenlafaxine (Pristiq)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Levomilnacipran (Fetzima)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Milnacipran (lxel/Savella)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

MAOI

Phenelzine (Nardil)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Selegiline (Eldepryl/Zelapar)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Selegiline patch (Emsam)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Tranylcypromine (Parnate)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

lsocarboxazid (Marplan)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

ATYPICAL

Bupropion (Wellbutrin) SR/ XL

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Nefazodone (Nefadar/Serzone)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Trazodone (Desyrel)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Esketamine (Spravato)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Brexanolone(Zulresso)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

AUGMENTING AGENT

Aripiprazole (Abilify)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Ziprasldone (Geodon)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Risperidone (Risperdal)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Quetiapine (Seroquel)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Olanzapine (Zyprexa)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Asenapine (Saphrls)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Cariprazine (Vraylar)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Lurasidone (Latuda)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Clozapine (Clozaril)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Paliperidone (lnvega)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

brexpiprazole (Rexulti)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Lithium (Eskallth/Llthobid/ Lithonate)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Gabapentin (Neurontin)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Lamotrigine (Lamictal)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

Topiramate (Topamax)

Dose (mg)

Start Date

End Date

Reason For Discontinuing

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(850) 254-9575
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info@tmsofemeraldcoast.com
403 Hollywood BIvd NW, Suite 104A Fort Walton Beach, FL 32548