Patient Forms Test - TMS Centers of Colorado

First Name
Last Name
Birthdate
SSN
I, the undersigned, authorize Dr. (enter name of TMS Center psychiatrist to the right) and the TMS Center of Colorado to: TMS Center of Colorado Psychiatrist's Name:
(select all that apply)	Release To (give info) Obtain From (request info)
(Provider's address, phone and fax numbers):
...the following information/records (select all that apply):	Presence and Progress in Tx Psychological Test Results History and Physical Psychiatric History Treatment Plan Medication Info Diagnosis Lab/X Ray results Other All of the Above
If other, specify
...for the purpose of (select all that apply)	Continuity of Care Third Party Payor Legal Representation Other
If other, specify
I understand that the information to be released may include information regarding drug or alcohol abuse and mental illness and treatment. I understand that I may revoke this consent at any time, verbally or in writing, except to the extent that it has already been acted upon. This consent will otherwise remain in force for 90 days, or until (add alternative date if desired) Print Name
Date