✓

Referral Received

Reference: —

Thank you for your referral. Our TMS team will review it and follow up with the client directly. Please quote the reference number in any correspondence.

rTMS Referral Form

Eligibility Screening

Halifax — 36 Solutions Dr, Suite 401, NS B3S 1N2

Greenwood — 963 Central Ave, Unit 19, NS B0P 1N0

Lincoln — 2398 Route 102, NB E3B 7G1

Inclusion Criteria

All three must be confirmed for eligibility

Criterion	✓
Male or female, must be ≥ 18 years of age
Primary or predominant diagnosis of major depressive disorder as a single or recurring episode, without psychotic features
Failure to achieve adequate improvement after ≥ 2 antidepressant trials at minimum effective doses in the current episode (antipsychotics excluded)

Exclusion Criteria

If any is present, the client is not eligible

⛔ If any exclusion criterion below is checked, the client is not eligible for rTMS treatment and should not be referred.

Criterion	Present
Cochlear implant(s) or other ferrous/conductive implants within 30 cm of the treatment coil
Active alcohol dependence
Pacemaker dependent

Possible Contraindications

To be reviewed by psychiatrist at assessment

⚠️ The items below are not automatic exclusions. Please flag any that apply — they will be reviewed and assessed by our psychiatrist prior to commencing treatment.

Possible Contraindication	Flag
Acute suicidality or threat to life from self-neglect
Pregnant, breastfeeding, or planning to become pregnant during the course of treatment
Other ferrous, conductive, or magnetic-sensitive metals in the head or within 30 cm of the treatment coil (e.g., aneurysm clips/coils, stents, bullet fragments, metal plates/screws)* * Does not include standard dental hardware
Personal history of epilepsy or seizure disorder, or a first-degree relative with idiopathic epilepsy
Active substance use (other than alcohol dependence) within the past 3–6 months (e.g., cocaine, crystal meth)
Inability to maintain stable medication, or currently taking high-dose seizure-threshold-lowering medications
Significant head injury, stroke, tumour, or prior neurosurgery

Date of Last Initial Assessment

Submitted referrals are transmitted over an encrypted connection and reviewed by the NuVista TMS team.

Referral Received

rTMS Referral Form

Inclusion Criteria

Exclusion Criteria

Possible Contraindications

rTMS Referral Form

Patient Information

Referring Provider

Preferred Clinic Location

Referral Priority