New Patient Form Patient Information:Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneCell PhonePlease check this box if you do NOT want us to leave a voicemail on the phone numbers lists. Do NOT leave voicemails. Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeSex* Male Female How'd you find out about us?*Please select one of the following options in the dropdown.PhysicianFriend, family, colleagueGoogle adYahoo, Bing, Ask.com or other internet searchSocial Media (Facebook, Twitter, LinkedIn, etc.)Insurance companyNeuroStarOtherIf other, please explain.Who referred you to this practice?*Personal Information:Spouse's Name First Last Spouse's PhonePatient Employer/OccupationPatient Employer / Business PhoneEmergency Contact Information:Emergency Contact Name* First Last Emergency Contact Phone*Person responsible for charges incurred:If a person other than the patient is responsible for this bill, please complete the GUARANTOR FORM.Relationship to patient:If patient is Minor or Student Dependent:Mother's Name First Last Father's Name First Last PhoneInsurance and Payment Information:We will file each visit with your primary insurance company. Please provide us with all information necessary to bill your insurance company. Please make sure we have current and correct information. Regardless of the status of your insurance, you are responsible for any balance. Payment is expected at the time of service unless prior arrangements are made with our billing department. Payment may be made by cash, check or credit card (Visa, Master Card, American Express or Discover). Any balances will be due upon receipt of our monthly statement. Accounts over 30 days are subject to a late fee. We are happy to file insurance for you; however, we cannot guarantee payment from them.Insurance company:ID #Insured's Name: First Last Insured's Date of Birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Office Hours:Office hours are by appointment Monday - Friday. The front office is open Monday - Friday, 8:00 a.m. - 5:30 p.m. If you need to contact the office regarding an appointment, billing questions or for general needs, please call during these hours. If you need to speak with your doctor between office visits, please call the office between 8:00 a.m. - 5:30 p.m. We will be able to get a message to your doctor requesting a callback.Emergencies:Call Dr. West's answering service at 615.327.4877. They will page your doctor or the call doctor for any emergencies you may have after hours. If you cannot wait, please call 911.Appointment Changes / CancellationsPatients will be charged the full session rate when cancellations occur unless notice is given at least one business day in advance. Patients will also be charged the full session rate in the event they fail to keep their appointment. Insurance does not cover missed or canceled appointments. If you need to change or reschedule an appointment, please call our office as soon as you can so we can accommodate other patients who wish to be seen. As a courtesy and convenience to our patients, we can keep a credit card on file for you to charge at your appointments. We will then mail you a receipt. Credit Card Payment*For security purposes, your credit card/debit card information will be taken either over the phone or in-office. I/we authorize Nashville TMS, PLLC to bill my credit card/debit card on file for professional services at the time of service. I will notify Nashville TMS, PLLC in writing if I no longer want my credit/debit card billed. I authorize Nashville TMS, PLLC to charge my credit/debit card on file when the patient does not give advance notice for a late cancellation or no-show, as per the policies. I understand that if I do not want my credit card billed for this purpose, I am still responsible for these fees and will be billed accordingly. Acknowledge and Agree Download a Copy of: Notice of Privacy PracticesCAPTCHA | Spam FilterPlease check the box so we know you're a real person.NameThis field is for validation purposes and should be left unchanged.