Lead {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
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Manufacturer        
  {Product Family -Medtronic Only}

Location
Right Atrium   Superior Vena Cava
Right Ventricle   Coronary Sinus
Left Atrium    
Left Ventricle    

Pacing/Sensing Thresholds Lead measurements as measured by PSA or equivalent
Pulse Width   Voltage   Current
. ms   . V   ma
    Impedance   Sensing
    ohms   P/R Wave . mV

Defibrillation Measurements
High Voltage Pathway   DFT/LED  
  J   ohms

Previous Device Data
Model Number   Serial/Lot Number
 
Device Manufacturer
 
  Prior Implant Date
   
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